Provider Demographics
NPI:1407898398
Name:GRAVES, MARK (LMSW)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:GRAVES
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 MORRIS AVE
Mailing Address - Street 2:SUITE 117
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49440-1104
Mailing Address - Country:US
Mailing Address - Phone:231-725-8143
Mailing Address - Fax:231-722-6484
Practice Address - Street 1:450 MORRIS AVE
Practice Address - Street 2:SUITE 117
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49440-1104
Practice Address - Country:US
Practice Address - Phone:231-725-8143
Practice Address - Fax:231-722-6484
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-12
Last Update Date:2009-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010339301041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1036857OtherCIGNA #
MIP11126253OtherMULTIPLAN #
MI131428OtherCOMPSYCH #
MI1712452Medicare PIN
MI131428OtherCOMPSYCH #