Provider Demographics
NPI:1104193820
Name:GRAVES, RYAN MAURICE JR (AMFT123441)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:MAURICE
Last Name:GRAVES
Suffix:JR
Gender:M
Credentials:AMFT123441
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15305 RAYEN ST
Mailing Address - Street 2:
Mailing Address - City:NORTH HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91343-5117
Mailing Address - Country:US
Mailing Address - Phone:626-376-7956
Mailing Address - Fax:
Practice Address - Street 1:15305 RAYEN ST
Practice Address - Street 2:
Practice Address - City:NORTH HILLS
Practice Address - State:CA
Practice Address - Zip Code:91343-5117
Practice Address - Country:US
Practice Address - Phone:626-376-7956
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-23
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT123441106H00000X
CA101YM0800X
225400000X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7184OtherMEDI-CAL
CA7667OtherMEDI-CAL
CA7368OtherMEDI-CAL
CA7708OtherMEDI-CAL