Provider Demographics
NPI:1699888545
Name:GRAVES, RICHARD ALLEN (MA CCC-A)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:ALLEN
Last Name:GRAVES
Suffix:
Gender:M
Credentials:MA CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2238 CHURCHILL DR
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:IL
Mailing Address - Zip Code:61873-9412
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:ILLIANA VAMC
Practice Address - Street 2:1900 EAST MAIN ST
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61832
Practice Address - Country:US
Practice Address - Phone:217-554-5622
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL14700927231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist