Provider Demographics
NPI:1396802765
Name:GRADY-DOLAN, THERESE (LISW)
Entity type:Individual
Prefix:
First Name:THERESE
Middle Name:
Last Name:GRADY-DOLAN
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3345 GLENMORE AVE
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45211-6543
Mailing Address - Country:US
Mailing Address - Phone:513-481-7500
Mailing Address - Fax:513-481-6316
Practice Address - Street 1:3345 GLENMORE AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45211-6543
Practice Address - Country:US
Practice Address - Phone:513-481-7500
Practice Address - Fax:513-481-6316
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI-00085131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH5W26781Medicare ID - Type Unspecified