Healthcare Provider Details

I. General information

NPI: 1205815933
Provider Name (Legal Business Name): TERESA MAE BRADY
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

258 NE TUDOR RD
LEES SUMMIT MO
64086-5696
US

IV. Provider business mailing address

405 SW WATERFALL CT
LEES SUMMIT MO
64081-1793
US

V. Phone/Fax

Practice location:
  • Phone: 816-347-0303
  • Fax: 816-347-0160
Mailing address:
  • Phone: 816-524-5177
  • Fax: 816-347-0160

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number103112
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: