Provider Demographics
NPI:1427713221
Name:GRAVES, MARIE ANTOINETTE
Entity type:Individual
Prefix:MS
First Name:MARIE
Middle Name:ANTOINETTE
Last Name:GRAVES
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 1:18726 S WESTERN AVE STE 408
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90248-3858
Mailing Address - Country:US
Mailing Address - Phone:310-856-0800
Mailing Address - Fax:855-568-2494
Practice Address - Street 1:8555 AERO DR STE 201
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1745
Practice Address - Country:US
Practice Address - Phone:858-244-5176
Practice Address - Fax:855-568-2494
Is Sole Proprietor?:No
Enumeration Date:2021-11-05
Last Update Date:2021-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician