Provider Demographics
NPI:1225053705
Name:GRAVES, TINA MARIE (MSW,LCSW,LMFT)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:MARIE
Last Name:GRAVES
Suffix:
Gender:F
Credentials:MSW,LCSW,LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2276
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39505-2276
Mailing Address - Country:US
Mailing Address - Phone:228-832-3362
Mailing Address - Fax:888-241-6012
Practice Address - Street 1:100 TERRI RD
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-3336
Practice Address - Country:US
Practice Address - Phone:228-832-3362
Practice Address - Fax:888-241-6012
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2010-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSC5073101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00118808Medicaid
MS800000156Medicare ID - Type UnspecifiedMEDICARE NUMBER