Provider Demographics
NPI:1386122760
Name:GRAGG, COLLEEN R
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:R
Last Name:GRAGG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:729 6TH ST
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:OH
Mailing Address - Zip Code:45662-4030
Mailing Address - Country:US
Mailing Address - Phone:740-876-8290
Mailing Address - Fax:740-529-1205
Practice Address - Street 1:729 6TH ST
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:OH
Practice Address - Zip Code:45662-4030
Practice Address - Country:US
Practice Address - Phone:740-876-8290
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-30
Last Update Date:2018-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0127424Medicaid