Provider Demographics
NPI:1437462322
Name:GRAVES, MARJORIE
Entity Type:Individual
Prefix:MRS
First Name:MARJORIE
Middle Name:
Last Name:GRAVES
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:MARNIE
Other - Middle Name:
Other - Last Name:GRAVES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:512 RIDGEMOOR DR
Mailing Address - Street 2:
Mailing Address - City:WILLLLOWBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60527
Mailing Address - Country:US
Mailing Address - Phone:630-258-1957
Mailing Address - Fax:630-654-1990
Practice Address - Street 1:512 RIDGEMOOR DR
Practice Address - Street 2:
Practice Address - City:WILLOWBROOK
Practice Address - State:IL
Practice Address - Zip Code:60527-5319
Practice Address - Country:US
Practice Address - Phone:630-258-1957
Practice Address - Fax:630-654-1990
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-20
Last Update Date:2010-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist