Provider Demographics
NPI:1366053340
Name:GRAVENSTEIN, MEGAN ELIZABETH
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:ELIZABETH
Last Name:GRAVENSTEIN
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 1:9942 CULVER BLVD UNIT 361
Mailing Address - Street 2:
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90232-4119
Mailing Address - Country:US
Mailing Address - Phone:818-996-1051
Mailing Address - Fax:
Practice Address - Street 1:2650 E FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91107-3439
Practice Address - Country:US
Practice Address - Phone:626-577-2261
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-12
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA119711106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist