Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 102L00000X | Psychologist | PY01609 | MO |
Y | 103T00000X | Psychologist | PY01609 | MO |
NPI | 1013049154 |
---|---|
Provider Name | Dr. Donald Ray Brady |
First Address | Blue Springs, MO 64015-8300 |
Second Address | Blue Springs, MO 64015-8300 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/03/2007 |
Last Update Date | 30/12/2016 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
MA1771001 | MEDICARE PTAN (01) | MO |