Provider Demographics
NPI:1083847750
Name:GRADY, MARY JANELL (MED, CP CADAC, LAD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:JANELL
Last Name:GRADY
Suffix:
Gender:F
Credentials:MED, CP CADAC, LAD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:76 NORCROSS ST
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:MA
Mailing Address - Zip Code:01851-4905
Mailing Address - Country:US
Mailing Address - Phone:978-937-5917
Mailing Address - Fax:
Practice Address - Street 1:11 UNION ST
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:MA
Practice Address - Zip Code:01840-1815
Practice Address - Country:US
Practice Address - Phone:978-685-1337
Practice Address - Fax:978-681-1281
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-28
Last Update Date:2009-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1301AD101YA0400X
MA2158101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)