Provider Demographics
NPI:1932564127
Name:O'GRADY, SHANNON (MFT, PHD)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:O'GRADY
Suffix:
Gender:F
Credentials:MFT, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9414 W LAKE MEAD BLVD
Mailing Address - Street 2:SUITE 212
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89134-8312
Mailing Address - Country:US
Mailing Address - Phone:505-660-8981
Mailing Address - Fax:
Practice Address - Street 1:9414 W LAKE MEAD BLVD
Practice Address - Street 2:SUITE 212
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89134-8312
Practice Address - Country:US
Practice Address - Phone:505-660-8981
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-15
Last Update Date:2015-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVMIO630106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist