Provider Demographics
NPI:1578254348
Name:GRADY, DEDRICK MICHELLE (MSW)
Entity Type:Individual
Prefix:
First Name:DEDRICK
Middle Name:MICHELLE
Last Name:GRADY
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1867 CRANE RIDGE DR STE 150C
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4910
Mailing Address - Country:US
Mailing Address - Phone:662-372-2033
Mailing Address - Fax:
Practice Address - Street 1:609 E CHURCH ST
Practice Address - Street 2:
Practice Address - City:BOONEVILLE
Practice Address - State:MS
Practice Address - Zip Code:38829-3711
Practice Address - Country:US
Practice Address - Phone:662-728-2488
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-15
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker