Provider Demographics
NPI:1811404130
Name:GRAVES, LEARA M (LAC)
Entity Type:Individual
Prefix:
First Name:LEARA
Middle Name:M
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 1:1370 SAINT NICHOLAS AVE APT 18S
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10033-6231
Mailing Address - Country:US
Mailing Address - Phone:646-639-3408
Mailing Address - Fax:
Practice Address - Street 1:3682 BROADWAY STE 2
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10031-1526
Practice Address - Country:US
Practice Address - Phone:646-400-9613
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-09
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020384-01225700000X
NY005705-1171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty