Healthcare Provider Details

I. General information

NPI: 1962773986
Provider Name (Legal Business Name): COURTNEY R GRADY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2012
Last Update Date: 02/21/2022
Certification Date: 02/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3751 PENNRIDGE DR STE 119
BRIDGETON MO
63044-1244
US

IV. Provider business mailing address

2707 BROWNS LN
JONESBORO AR
72401-7213
US

V. Phone/Fax

Practice location:
  • Phone: 314-443-7776
  • Fax: 949-561-4148
Mailing address:
  • Phone: 870-972-4939
  • Fax: 870-972-4911

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: