Basic Information
| Provider Information | |||||||||
| NPI: | 1497786313 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRADY | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | LPCS, NCC, DCC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7253 MANOR OAKS DRIVE | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9196090954 | ||||||||
| FaxNumber: | 9198967537 | ||||||||
| Practice Location | |||||||||
| Address1: | 16 BERMUDA LANDING PLACE | ||||||||
| Address2: | |||||||||
| City: | NORTH TOPSAIL BEACH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 26460 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9196090954 | ||||||||
| FaxNumber: | 9198967537 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2006 | ||||||||
| LastUpdateDate: | 03/17/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 4766 | NC | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YM0800X | 4766S | NC | N | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 6102727 | 05 | NC | MEDICAID |