Provider Demographics
NPI:1518063171
Name:GRAVES, MICHAEL ALLEN (PHD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ALLEN
Last Name:GRAVES
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:879 14TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94114-1211
Mailing Address - Country:US
Mailing Address - Phone:415-255-8709
Mailing Address - Fax:
Practice Address - Street 1:879 14TH ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94114-1211
Practice Address - Country:US
Practice Address - Phone:415-255-8709
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY13468103T00000X, 103TP2701X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY13468OtherLICENSE NUMBER
CA0PL134680Medicare ID - Type Unspecified