Provider Demographics
NPI:1417389057
Name:SEAGRAVES, EMILY BERRY
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:BERRY
Last Name:SEAGRAVES
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 1:2600 S EL CAMINO REAL
Mailing Address - Street 2:STE 200
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94403-2380
Mailing Address - Country:US
Mailing Address - Phone:650-578-8691
Mailing Address - Fax:
Practice Address - Street 1:900 E MAIN ST STE 200
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-5853
Practice Address - Country:US
Practice Address - Phone:323-513-3724
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-06
Last Update Date:2021-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CA78664104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health