Provider Demographics
NPI:1730732835
Name:O'GRADY, MARY
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:O'GRADY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:808 PINE ALLEY ST
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-1216
Mailing Address - Country:US
Mailing Address - Phone:850-380-2586
Mailing Address - Fax:
Practice Address - Street 1:1200 HAWTHORN HOUSE DR
Practice Address - Street 2:
Practice Address - City:SHALIMAR
Practice Address - State:FL
Practice Address - Zip Code:32579-1168
Practice Address - Country:US
Practice Address - Phone:850-380-2586
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-18
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA7235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist