Provider Demographics
NPI:1629511704
Name:GRAVES, ELISE (MA RADT1)
Entity Type:Individual
Prefix:
First Name:ELISE
Middle Name:
Last Name:GRAVES
Suffix:
Gender:F
Credentials:MA RADT1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27281 LAS RAMBLAS STE 140
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-6387
Mailing Address - Country:US
Mailing Address - Phone:949-540-0170
Mailing Address - Fax:949-540-0173
Practice Address - Street 1:27281 LAS RAMBLAS STE 140
Practice Address - Street 2:
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691
Practice Address - Country:US
Practice Address - Phone:949-540-0170
Practice Address - Fax:949-540-0173
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-22
Last Update Date:2018-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA465642989OtherTIN