Provider Demographics
NPI:1821141839
Name:GRADDY, LISA TODD (LCSW, MS)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:TODD
Last Name:GRADDY
Suffix:
Gender:F
Credentials:LCSW, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 AMSDEN AVE
Mailing Address - Street 2:SUITE #402
Mailing Address - City:VERSAILLES
Mailing Address - State:KY
Mailing Address - Zip Code:40383-1851
Mailing Address - Country:US
Mailing Address - Phone:859-608-3578
Mailing Address - Fax:859-846-4904
Practice Address - Street 1:360 AMSDEN AVE
Practice Address - Street 2:SUITE #402
Practice Address - City:VERSAILLES
Practice Address - State:KY
Practice Address - Zip Code:40383-1851
Practice Address - Country:US
Practice Address - Phone:859-608-3578
Practice Address - Fax:859-846-4904
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1790101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYCSW0280Medicare ID - Type UnspecifiedLCSW