Provider Demographics
NPI:1598883225
Name:GRAVER, CRYSTAL LEIGH
Entity Type:Individual
Prefix:MRS
First Name:CRYSTAL
Middle Name:LEIGH
Last Name:GRAVER
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 1:951 W COLLEGE ST
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MO
Mailing Address - Zip Code:63379-1112
Mailing Address - Country:US
Mailing Address - Phone:636-528-7652
Mailing Address - Fax:636-528-2411
Practice Address - Street 1:LINCOLN COUNTY REORGANIZED
Practice Address - Street 2:951 W COLLEGE ST
Practice Address - City:TROY
Practice Address - State:MO
Practice Address - Zip Code:63379-1112
Practice Address - Country:US
Practice Address - Phone:636-528-7652
Practice Address - Fax:636-528-2411
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2009-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002007285235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO467510301Medicaid