Provider Demographics
NPI:1124686241
Name:DEDRICK, GRADY EMILY (LPC, SAC-IT, CCAT)
Entity type:Individual
Prefix:MISS
First Name:GRADY
Middle Name:EMILY
Last Name:DEDRICK
Suffix:
Gender:F
Credentials:LPC, SAC-IT, CCAT
Other - Prefix:
Other - First Name:GRADY
Other - Middle Name:EMILY
Other - Last Name:KEDING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:304 BICKFORD ST
Mailing Address - Street 2:
Mailing Address - City:NEW LISBON
Mailing Address - State:WI
Mailing Address - Zip Code:53950-1533
Mailing Address - Country:US
Mailing Address - Phone:608-562-3976
Mailing Address - Fax:608-562-3975
Practice Address - Street 1:304 BICKFORD ST
Practice Address - Street 2:
Practice Address - City:NEW LISBON
Practice Address - State:WI
Practice Address - Zip Code:53950-1533
Practice Address - Country:US
Practice Address - Phone:608-562-3976
Practice Address - Fax:608-562-3975
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-04
Last Update Date:2022-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
WI8436-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No171M00000XOther Service ProvidersCase Manager/Care Coordinator