Provider Demographics
NPI:1386190585
Name:BRADY, MATTHEW R (AUD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:R
Last Name:BRADY
Suffix:
Gender:M
Credentials:AUD
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 813
Mailing Address - Street 2:200 POCAHONTAS TRAIL
Mailing Address - City:WHITE SULPHUR SPRINGS
Mailing Address - State:WV
Mailing Address - Zip Code:24986-0813
Mailing Address - Country:US
Mailing Address - Phone:304-536-5030
Mailing Address - Fax:304-536-5031
Practice Address - Street 1:301 LOUIS ST
Practice Address - Street 2:SUITE 101
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-5181
Practice Address - Country:US
Practice Address - Phone:423-246-4600
Practice Address - Fax:423-246-3311
Is Sole Proprietor?:No
Enumeration Date:2016-08-28
Last Update Date:2016-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1774231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ023491Medicaid