Provider Demographics
NPI:1417309386
Name:GRADY, MATTHEW (LMSW)
Entity Type:Individual
Prefix:MRS
First Name:MATTHEW
Middle Name:
Last Name:GRADY
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 PANTIGO PL
Mailing Address - Street 2:SUITE I
Mailing Address - City:EAST HAMPTON
Mailing Address - State:NY
Mailing Address - Zip Code:11937-5920
Mailing Address - Country:US
Mailing Address - Phone:631-329-8430
Mailing Address - Fax:631-329-8291
Practice Address - Street 1:200 PANTIGO PL
Practice Address - Street 2:SUITE I
Practice Address - City:EAST HAMPTON
Practice Address - State:NY
Practice Address - Zip Code:11937-5920
Practice Address - Country:US
Practice Address - Phone:631-329-8430
Practice Address - Fax:631-329-8291
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-05
Last Update Date:2016-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY72 049339101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional