Provider Demographics
NPI:1063630077
Name:LA GRAVE, THOMAS J JR (LCSW)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:J
Last Name:LA GRAVE
Suffix:JR
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 CALIFORNIA DRIVE
Mailing Address - Street 2:
Mailing Address - City:YOUNTVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94599-1418
Mailing Address - Country:US
Mailing Address - Phone:707-944-4575
Mailing Address - Fax:707-944-4590
Practice Address - Street 1:150 CALIFORNIA DRIVE
Practice Address - Street 2:
Practice Address - City:YOUNTVILLE
Practice Address - State:CA
Practice Address - Zip Code:94599-1418
Practice Address - Country:US
Practice Address - Phone:707-944-4575
Practice Address - Fax:707-944-4590
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS 238001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical