Provider Demographics
NPI:1376909432
Name:GRAVELINE, GEORGE CHRISTOPHER (CADC II #A062350323)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:CHRISTOPHER
Last Name:GRAVELINE
Suffix:
Gender:M
Credentials:CADC II #A062350323
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:641 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:KING CITY
Mailing Address - State:CA
Mailing Address - Zip Code:93930-3231
Mailing Address - Country:US
Mailing Address - Phone:813-525-8181
Mailing Address - Fax:831-525-8130
Practice Address - Street 1:641 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:KING CITY
Practice Address - State:CA
Practice Address - Zip Code:93930-3231
Practice Address - Country:US
Practice Address - Phone:813-525-8181
Practice Address - Fax:831-525-8130
Is Sole Proprietor?:No
Enumeration Date:2016-01-05
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA062350323101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)