Provider Demographics
NPI:1467660803
Name:BRADY, DOUGLAS O (PHD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:O
Last Name:BRADY
Suffix:
Gender:M
Credentials:PHD
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 6446
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73506-0446
Mailing Address - Country:US
Mailing Address - Phone:580-355-7474
Mailing Address - Fax:580-355-6765
Practice Address - Street 1:6601 W GORE BLVD.
Practice Address - Street 2:#6446
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-9998
Practice Address - Country:US
Practice Address - Phone:580-355-7474
Practice Address - Fax:580-355-6765
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2022-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX21363103T00000X
OK198103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK731279230001OtherBLUE CROSS BLUE SHIELD
OK731279230001OtherBLUE CROSS BLUE SHIELD