Provider Demographics
NPI:1417391673
Name:ELAM, GRADY (LMSW)
Entity Type:Individual
Prefix:MR
First Name:GRADY
Middle Name:
Last Name:ELAM
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 1:770 RIVERSIDE AVE
Mailing Address - Street 2:SUITE 11
Mailing Address - City:ADRIAN
Mailing Address - State:MI
Mailing Address - Zip Code:49221-1476
Mailing Address - Country:US
Mailing Address - Phone:517-264-2244
Mailing Address - Fax:
Practice Address - Street 1:770 RIVERSIDE AVE
Practice Address - Street 2:SUITE 11
Practice Address - City:ADRIAN
Practice Address - State:MI
Practice Address - Zip Code:49221-1476
Practice Address - Country:US
Practice Address - Phone:517-264-2244
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-18
Last Update Date:2013-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010780821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical