Provider Demographics
NPI:1285709410
Name:O'GRADY, DIANE PATRICIA (RN, CNS)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:PATRICIA
Last Name:O'GRADY
Suffix:
Gender:F
Credentials:RN, CNS
Other - Prefix:
Other - First Name:DIANA
Other - Middle Name:PATRICIA
Other - Last Name:BAKDASH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN, CNS
Mailing Address - Street 1:7945 STONE CREEK DRIVE
Mailing Address - Street 2:SUITE 130
Mailing Address - City:CHANHASSEN
Mailing Address - State:MN
Mailing Address - Zip Code:55317
Mailing Address - Country:US
Mailing Address - Phone:952-241-4050
Mailing Address - Fax:952-241-4049
Practice Address - Street 1:7945 STONE CREEK DRIVE
Practice Address - Street 2:SUITE 130
Practice Address - City:CHANHASSEN
Practice Address - State:MN
Practice Address - Zip Code:55317
Practice Address - Country:US
Practice Address - Phone:952-241-4050
Practice Address - Fax:952-241-4049
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-22
Last Update Date:2012-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR07494652084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN024042700Medicaid
MN642K4BAOtherBCBS