Provider Demographics
NPI:1366792897
Name:GRADY, KRISTEN WADE (OTR/L)
Entity type:Individual
Prefix:MS
First Name:KRISTEN
Middle Name:WADE
Last Name:GRADY
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:738 MCADAMS ST.
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62246
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1610 N LAKEWOOD DR
Practice Address - Street 2:
Practice Address - City:EFFINGHAM
Practice Address - State:IL
Practice Address - Zip Code:62401
Practice Address - Country:US
Practice Address - Phone:217-347-7781
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-12
Last Update Date:2012-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.009023225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist