Provider Demographics
NPI:1053681312
Name:GRADDY, SARAH RENEE (PTA)
Entity type:Individual
Prefix:
First Name:SARAH
Middle Name:RENEE
Last Name:GRADDY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 GUNNAR LOOP
Mailing Address - Street 2:
Mailing Address - City:PARAGOULD
Mailing Address - State:AR
Mailing Address - Zip Code:72450-3151
Mailing Address - Country:US
Mailing Address - Phone:870-273-8853
Mailing Address - Fax:
Practice Address - Street 1:4 GUNNAR LOOP
Practice Address - Street 2:
Practice Address - City:PARAGOULD
Practice Address - State:AR
Practice Address - Zip Code:72450-3151
Practice Address - Country:US
Practice Address - Phone:870-273-8853
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-04
Last Update Date:2012-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009024850225200000X
AR2346225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant