Provider Demographics
NPI:1922520162
Name:CAROLE A. GRADY LPCC
Entity Type:Organization
Organization Name:CAROLE A. GRADY LPCC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE-PROPRIETER
Authorized Official - Prefix:
Authorized Official - First Name:CAROLE
Authorized Official - Middle Name:A
Authorized Official - Last Name:GRADY
Authorized Official - Suffix:
Authorized Official - Credentials:LPCC, MED, CEP
Authorized Official - Phone:575-202-7576
Mailing Address - Street 1:145 ROBERTS DR
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88005-3073
Mailing Address - Country:US
Mailing Address - Phone:575-202-7576
Mailing Address - Fax:
Practice Address - Street 1:1570 W PICACHO AVE
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88005-2375
Practice Address - Country:US
Practice Address - Phone:575-202-7576
Practice Address - Fax:575-222-0659
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-10
Last Update Date:2017-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1944251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM59482788Medicaid