Provider Demographics
NPI:1619657814
Name:BRADY, TINA (LCDCLLL)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:BRADY
Suffix:
Gender:F
Credentials:LCDCLLL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1449 ACADEMY PL
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45406-4717
Mailing Address - Country:US
Mailing Address - Phone:470-469-7221
Mailing Address - Fax:
Practice Address - Street 1:1449 ACADEMY PL
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45406-4717
Practice Address - Country:US
Practice Address - Phone:470-469-7221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-21
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH162374101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty