Provider Demographics
NPI:1649408410
Name:GRADDICK, KALISHA MONIQUE (BA)
Entity Type:Individual
Prefix:
First Name:KALISHA
Middle Name:MONIQUE
Last Name:GRADDICK
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4570 SAINT JOHNS AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32210-1848
Mailing Address - Country:US
Mailing Address - Phone:904-389-5231
Mailing Address - Fax:904-677-8019
Practice Address - Street 1:4570 SAINT JOHNS AVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32210-1848
Practice Address - Country:US
Practice Address - Phone:904-389-5231
Practice Address - Fax:904-677-8019
Is Sole Proprietor?:No
Enumeration Date:2009-06-30
Last Update Date:2009-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL360358001Medicaid