Provider Demographics
NPI:1588402986
Name:GRADY FAMILY THERAPY AND CONSULTING PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:GRADY FAMILY THERAPY AND CONSULTING PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:GRADY
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD, LMFT
Authorized Official - Phone:608-436-6578
Mailing Address - Street 1:715 COHASSET CT APT 2
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92109-8122
Mailing Address - Country:US
Mailing Address - Phone:608-436-6578
Mailing Address - Fax:
Practice Address - Street 1:4305 GESNER ST STE 207
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92117-6685
Practice Address - Country:US
Practice Address - Phone:608-436-6578
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-18
Last Update Date:2024-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)