Provider Demographics
NPI:1699977835
Name:GRAVATT, KRISTIE
Entity type:Individual
Prefix:
First Name:KRISTIE
Middle Name:
Last Name:GRAVATT
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 1:316 NW VERMONT
Mailing Address - Street 2:STE. 50
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701
Mailing Address - Country:US
Mailing Address - Phone:541-330-0006
Mailing Address - Fax:541-330-0082
Practice Address - Street 1:316 NW VERMONT
Practice Address - Street 2:STE. 50
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701
Practice Address - Country:US
Practice Address - Phone:541-330-0006
Practice Address - Fax:541-330-0082
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)