Provider Demographics
NPI:1558412171
Name:GRAVES, MARTHA (AUD)
Entity Type:Individual
Prefix:MRS
First Name:MARTHA
Middle Name:
Last Name:GRAVES
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 S HENDERSON ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-1017
Mailing Address - Country:US
Mailing Address - Phone:817-335-2583
Mailing Address - Fax:817-335-2597
Practice Address - Street 1:3023 THOUSAND OAKS DR
Practice Address - Street 2:SUITE 105
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78247-3556
Practice Address - Country:US
Practice Address - Phone:210-494-2525
Practice Address - Fax:210-494-2526
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX51734231H00000X
237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXB128872Medicare PIN