MEDICARE: MRS. TERESA BENNETT BRADY MS, CGC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	170300000X	Genetic Counselor (M.S.)

General Provider Information

NPI Number	:	1114900917
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. TERESA BENNETT BRADY MS, CGC

Provider Business Mailing Address
First Line	:	7706 NOLAND WOODS DR
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28277-0243
Country	:	US
Telephone Number	:	704-321-2597
Fax Number	:

Provider Business Practice Location Address
First Line	:	1025 MOREHEAD MEDICAL ST
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28204-2839
Country	:	US
Telephone Number	:	704-355-3149
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/25/2005
Last Update Date	:	07/08/2007

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