Provider Demographics
NPI:1336738574
Name:GRATA, KIM L (CADC)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:L
Last Name:GRATA
Suffix:
Gender:F
Credentials:CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 ADDISON AVE W STE 1000
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-5853
Mailing Address - Country:US
Mailing Address - Phone:208-736-5048
Mailing Address - Fax:208-735-2126
Practice Address - Street 1:630 ADDISON AVE W STE 1000
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-5853
Practice Address - Country:US
Practice Address - Phone:208-736-5048
Practice Address - Fax:208-735-2126
Is Sole Proprietor?:No
Enumeration Date:2021-01-12
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDI1709684Medicaid