Provider Demographics
NPI:1063545234
Name:GRAVESEN, KATHERINE M (DC)
Entity type:Individual
Prefix:DR
First Name:KATHERINE
Middle Name:M
Last Name:GRAVESEN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 EAST LIPOA
Mailing Address - Street 2:#4-102
Mailing Address - City:KIHEI
Mailing Address - State:HI
Mailing Address - Zip Code:96753
Mailing Address - Country:US
Mailing Address - Phone:715-262-8555
Mailing Address - Fax:
Practice Address - Street 1:30 EAST LIPOA
Practice Address - Street 2:#4-102
Practice Address - City:KIHEI
Practice Address - State:HI
Practice Address - Zip Code:96753
Practice Address - Country:US
Practice Address - Phone:715-262-8555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2014-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3723-012111N00000X
HI1238111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor