Provider Demographics
NPI:1417206244
Name:GRADNEY, CONNIE R (LBSW)
Entity type:Individual
Prefix:
First Name:CONNIE
Middle Name:R
Last Name:GRADNEY
Suffix:
Gender:F
Credentials:LBSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2135 WILLOWGLEN DR.
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77707-0000
Mailing Address - Country:US
Mailing Address - Phone:409-861-4036
Mailing Address - Fax:409-861-4036
Practice Address - Street 1:2135 WILLOWGLEN DR.
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77707-0000
Practice Address - Country:US
Practice Address - Phone:409-861-4036
Practice Address - Fax:409-861-4036
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-07
Last Update Date:2012-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX51911104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker