Provider Demographics
NPI:1720851280
Name:GRADY, KELLIE (LPC)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:
Last Name:GRADY
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 BAILEY ST STE 2
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-4688
Mailing Address - Country:US
Mailing Address - Phone:517-273-2706
Mailing Address - Fax:
Practice Address - Street 1:300 BAILEY ST STE 2
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-4688
Practice Address - Country:US
Practice Address - Phone:517-273-2706
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-06
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6451022008101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional