Provider Demographics
NPI:1972750453
Name:GRADY, SHARON A (MA)
Entity type:Individual
Prefix:
First Name:SHARON
Middle Name:A
Last Name:GRADY
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 506
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:NM
Mailing Address - Zip Code:88435-0506
Mailing Address - Country:US
Mailing Address - Phone:505-795-2681
Mailing Address - Fax:
Practice Address - Street 1:239 S 4TH ST
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:NM
Practice Address - Zip Code:88435-2322
Practice Address - Country:US
Practice Address - Phone:575-472-5073
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-26
Last Update Date:2011-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0114921101YM0800X
NM0143121101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health