Provider Demographics
NPI:1780131417
Name:BRADDY, THERESA
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:BRADDY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1278 FM 407
Mailing Address - Street 2:SUITE 109 OFFICE #22
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75077-2200
Mailing Address - Country:US
Mailing Address - Phone:214-513-0747
Mailing Address - Fax:210-519-0316
Practice Address - Street 1:160 E VISTA RIDGE MALL DR
Practice Address - Street 2:1415
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75067-3716
Practice Address - Country:US
Practice Address - Phone:214-531-0747
Practice Address - Fax:210-519-0316
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-11
Last Update Date:2016-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX68047101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional