=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790621019
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CODY LANDON BRADY LCDC 17747
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/28/2026
-----------------------------------------------------
Last Update Date | 04/28/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3015 HERRING AVE
-----------------------------------------------------
City | WACO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76708-3238
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 254-299-2783
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3015 HERRING AVE
-----------------------------------------------------
City | WACO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76708-3238
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 254-299-2777
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 17747
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------