Provider Demographics
NPI:1578588612
Name:GRAVES, MICHELLE (LAC)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:GRAVES
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:744 UNION ST APT 4
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94133-2734
Mailing Address - Country:US
Mailing Address - Phone:415-272-9622
Mailing Address - Fax:
Practice Address - Street 1:220 MONTGOMERY ST STE 305
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94104-3444
Practice Address - Country:US
Practice Address - Phone:415-677-9900
Practice Address - Fax:415-358-5803
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC8883171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAC8883OtherSTATE LICENSE NO.