Healthcare Provider Details

I. General information

NPI: 1629604186
Provider Name (Legal Business Name): LISA ANN GRADY LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/17/2020
Last Update Date: 07/07/2026
Certification Date: 07/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

313 BENJAMIN ST
MARLIN TX
76661-2709
US

IV. Provider business mailing address

313 BENJAMIN ST
MARLIN TX
76661-2709
US

V. Phone/Fax

Practice location:
  • Phone: 254-495-3498
  • Fax: --
Mailing address:
  • Phone: 254-495-3498
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number82351
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: