Provider Demographics
NPI:1114222494
Name:GRAVES, AMY LYNN (BHRS)
Entity Type:Individual
Prefix:MS
First Name:AMY
Middle Name:LYNN
Last Name:GRAVES
Suffix:
Gender:F
Credentials:BHRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:612 E JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:HUGO
Mailing Address - State:OK
Mailing Address - Zip Code:74743-4025
Mailing Address - Country:US
Mailing Address - Phone:580-326-2200
Mailing Address - Fax:580-326-2201
Practice Address - Street 1:612 E JACKSON ST
Practice Address - Street 2:
Practice Address - City:HUGO
Practice Address - State:OK
Practice Address - Zip Code:74743-4025
Practice Address - Country:US
Practice Address - Phone:580-326-2200
Practice Address - Fax:580-326-2201
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-19
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100746580GMedicaid