Provider Demographics
NPI:1962838730
Name:GRADDY, BRANDI NICOLE (CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:BRANDI
Middle Name:NICOLE
Last Name:GRADDY
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 E HOWELL DR
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:GA
Mailing Address - Zip Code:31635-5522
Mailing Address - Country:US
Mailing Address - Phone:229-460-9735
Mailing Address - Fax:
Practice Address - Street 1:77 E HOWELL DR
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:GA
Practice Address - Zip Code:31635-5522
Practice Address - Country:US
Practice Address - Phone:229-460-9735
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-24
Last Update Date:2013-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP007267235Z00000X
FL10499235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist