Basic Information
| Provider Information | |||||||||
| NPI: | 1811216849 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OGRADY | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | ROBERT | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | LPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 517 SAN JULIAN ST | ||||||||
| Address2: | NO. 454 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900131547 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3233606762 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2555 E COLORADO BLVD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911076622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6265772261 | ||||||||
| FaxNumber: | 6265772354 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2010 | ||||||||
| LastUpdateDate: | 06/01/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 167G00000X | LPT32486 | CA | Y | Nursing Service Providers | Licensed Psychiatric Technician |
ID Information
| ID | Type | State | Issuer | Description | ICAN960 | 01 | CA | LA COUNTY DMH | OTHER |