Provider Demographics
NPI:1184955700
Name:GRADY, TARRAH A (LCSW)
Entity type:Individual
Prefix:
First Name:TARRAH
Middle Name:A
Last Name:GRADY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:TARRAH
Other - Middle Name:
Other - Last Name:HICKERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:2305 GEORGIA ST
Mailing Address - Street 2:
Mailing Address - City:LOUISIANA
Mailing Address - State:MO
Mailing Address - Zip Code:63353-2559
Mailing Address - Country:US
Mailing Address - Phone:573-754-4584
Mailing Address - Fax:
Practice Address - Street 1:2305 GEORGIA ST
Practice Address - Street 2:
Practice Address - City:LOUISIANA
Practice Address - State:MO
Practice Address - Zip Code:63353-2559
Practice Address - Country:US
Practice Address - Phone:573-754-4584
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-21
Last Update Date:2024-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20100011051041C0700X
IL1490161321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
F00098035Medicare PIN