Provider Demographics
NPI:1265863336
Name:GRAVITTER, AMBER
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:
Last Name:GRAVITTER
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 1:2701 LARSEN RD
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54303-4863
Mailing Address - Country:US
Mailing Address - Phone:920-593-8041
Mailing Address - Fax:
Practice Address - Street 1:2701 LARSEN RD
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-4863
Practice Address - Country:US
Practice Address - Phone:920-593-8041
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-27
Last Update Date:2013-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1635-226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional