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General NPI Number Information
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NPI Number | 1376825869
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Entity Type | Individual
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Provider Name | RYAN D GRADY
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Gender | Male
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Dates
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Enumeration Date | 09/12/2011
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Last Update Date | 08/10/2020
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Provider Practice Location Address
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Address Line | 3217 ETTRICK ST
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City | LOS ANGELES
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State | CA
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Zip | 90027-2503
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Country | US
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Telephone | 213-927-5451
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 292161
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City | LOS ANGELES
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State | CA
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Zip | 90029-8661
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Country | US
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Telephone | 213-927-5451
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 34093
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License Number State | CA
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