Provider Demographics
NPI:1033557376
Name:GRAVES, LEISA ANN (LMSW)
Entity Type:Individual
Prefix:MS
First Name:LEISA
Middle Name:ANN
Last Name:GRAVES
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1564 US 20 E
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH
Mailing Address - State:IL
Mailing Address - Zip Code:61028-9745
Mailing Address - Country:US
Mailing Address - Phone:815-238-2865
Mailing Address - Fax:563-822-1073
Practice Address - Street 1:953 1/2 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:IA
Practice Address - Zip Code:52057-1836
Practice Address - Country:US
Practice Address - Phone:815-238-2865
Practice Address - Fax:563-822-1073
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-10
Last Update Date:2013-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA007286104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker