Provider Demographics
NPI:1376825869
Name:GRADY, RYAN D
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:D
Last Name:GRADY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 292161
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90029-8661
Mailing Address - Country:US
Mailing Address - Phone:213-927-5451
Mailing Address - Fax:
Practice Address - Street 1:3217 ETTRICK ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-2503
Practice Address - Country:US
Practice Address - Phone:213-927-5451
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-12
Last Update Date:2020-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34093101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health