Healthcare Provider Details

I. General information

NPI: 1760634190
Provider Name (Legal Business Name): TYRISHA GENEA SMITH-GRADY MSW STUDENT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2008
Last Update Date: 12/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2730 ADELINE ST
OAKLAND CA
94607-2408
US

IV. Provider business mailing address

2730 ADELINE ST
OAKLAND CA
94607-2408
US

V. Phone/Fax

Practice location:
  • Phone: 510-465-1800
  • Fax: 510-465-1508
Mailing address:
  • Phone: 510-465-1800
  • Fax: 510-465-1508

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: