Provider Demographics
NPI:1760560197
Name:BRADY, MARIANNE J (PHD)
Entity Type:Individual
Prefix:MS
First Name:MARIANNE
Middle Name:J
Last Name:BRADY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 SUPERIOR AVE
Mailing Address - Street 2:
Mailing Address - City:BARAGA
Mailing Address - State:MI
Mailing Address - Zip Code:49908
Mailing Address - Country:US
Mailing Address - Phone:906-353-8700
Mailing Address - Fax:906-353-8799
Practice Address - Street 1:102 SUPERIOR AVE
Practice Address - Street 2:
Practice Address - City:BARAGA
Practice Address - State:MI
Practice Address - Zip Code:49908
Practice Address - Country:US
Practice Address - Phone:906-353-8700
Practice Address - Fax:906-353-8799
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301011865103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
S14686Medicare UPIN
MI231845Medicare ID - Type UnspecifiedFQHC