Provider Demographics
NPI:1821429440
Name:FRADY, ROBERT
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:FRADY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 495
Mailing Address - Street 2:
Mailing Address - City:BALDWIN
Mailing Address - State:GA
Mailing Address - Zip Code:30511-0495
Mailing Address - Country:US
Mailing Address - Phone:706-968-9150
Mailing Address - Fax:
Practice Address - Street 1:1627 WYNN LAKE RD
Practice Address - Street 2:
Practice Address - City:ALTO
Practice Address - State:GA
Practice Address - Zip Code:30510-5226
Practice Address - Country:US
Practice Address - Phone:706-968-9150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-07
Last Update Date:2013-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY001124103T00000X, 103TC0700X, 103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service