Provider Demographics
NPI:1275887523
Name:GRADY, BARBARA TELISA
Entity Type:Individual
Prefix:
First Name:BARBARA
Middle Name:TELISA
Last Name:GRADY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:815 GERLACH DR
Mailing Address - Street 2:525
Mailing Address - City:DURANT
Mailing Address - State:OK
Mailing Address - Zip Code:74701-2562
Mailing Address - Country:US
Mailing Address - Phone:580-775-2304
Mailing Address - Fax:
Practice Address - Street 1:1327 N 16TH AVE
Practice Address - Street 2:
Practice Address - City:DURANT
Practice Address - State:OK
Practice Address - Zip Code:74701-2134
Practice Address - Country:US
Practice Address - Phone:580-931-9064
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-07
Last Update Date:2012-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200287120AMedicaid