Provider Demographics
NPI:1245695899
Name:O'NEILL, GRADY (MA)
Entity type:Individual
Prefix:
First Name:GRADY
Middle Name:
Last Name:O'NEILL
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 5TH AVE N
Mailing Address - Street 2:
Mailing Address - City:HURLEY
Mailing Address - State:WI
Mailing Address - Zip Code:54534-1208
Mailing Address - Country:US
Mailing Address - Phone:715-329-1288
Mailing Address - Fax:
Practice Address - Street 1:115 5TH AVE N
Practice Address - Street 2:
Practice Address - City:HURLEY
Practice Address - State:WI
Practice Address - Zip Code:54534-1208
Practice Address - Country:US
Practice Address - Phone:715-329-1288
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-28
Last Update Date:2025-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12076-125101YP2500X
MI2-01483101YA0400X
WI217-36221700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist