Healthcare Provider Details

I. General information

NPI: 1811951569
Provider Name (Legal Business Name): MATTHEW EDWARD GRADY LCSW CADC III
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/12/2006
Last Update Date: 01/06/2022
Certification Date: 01/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1675 WINTER ST NE
SALEM OR
97303
US

IV. Provider business mailing address

9605 GRAND RONDE RD
GRAND RONDE OR
97347-9712
US

V. Phone/Fax

Practice location:
  • Phone: 503-585-0351
  • Fax: 503-585-0212
Mailing address:
  • Phone: 503-879-2060
  • Fax: 503-879-2071

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number031171
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberL3658
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: