Healthcare Provider Details

I. General information

NPI: 1346629094
Provider Name (Legal Business Name): GRADA BERRY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/28/2015
Last Update Date: 05/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2520 HEATHER BROOK LN APT 804
ARLINGTON TX
76006-5177
US

IV. Provider business mailing address

PO BOX 540574
GRAND PRAIRIE TX
75054-0574
US

V. Phone/Fax

Practice location:
  • Phone: 817-633-0383
  • Fax: 817-633-0084
Mailing address:
  • Phone: 817-633-0383
  • Fax: 817-633-0084

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number016187
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: