Provider Demographics
NPI:1205395829
Name:GRAVES, ANGELA M
Entity Type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:M
Last Name:GRAVES
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 1:3229 S CHEROKEE LN STE 1400
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188-4461
Mailing Address - Country:US
Mailing Address - Phone:470-499-2482
Mailing Address - Fax:
Practice Address - Street 1:3229 S CHEROKEE LN STE 1400
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188
Practice Address - Country:US
Practice Address - Phone:470-499-2482
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-13
Last Update Date:2019-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORABA-IN-10193688106S00000X
GARBT-19-91959106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician