Provider Demographics
NPI:1295465607
Name:GRAVERT, BETHANY (MA, LPC, SCL)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:
Last Name:GRAVERT
Suffix:
Gender:F
Credentials:MA, LPC, SCL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 MARIETTA ST NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49505-5117
Mailing Address - Country:US
Mailing Address - Phone:815-590-0661
Mailing Address - Fax:
Practice Address - Street 1:3800 LAKE MICHIGAN DR NW STE 103
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49534-4583
Practice Address - Country:US
Practice Address - Phone:616-805-3660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-16
Last Update Date:2022-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401222654101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional