Provider Demographics
NPI:1356638274
Name:GRADY, SHANA
Entity Type:Individual
Prefix:
First Name:SHANA
Middle Name:
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 1:8140 ASHTON AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20109-5698
Mailing Address - Country:US
Mailing Address - Phone:703-330-9933
Mailing Address - Fax:703-368-8454
Practice Address - Street 1:8140 ASHTON AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20109-5698
Practice Address - Country:US
Practice Address - Phone:703-330-9933
Practice Address - Fax:703-368-8454
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-29
Last Update Date:2011-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810004407103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical