Provider Demographics
NPI:1821200858
Name:GRAVES, CLIFFORD STANLEY (DMIN)
Entity Type:Individual
Prefix:
First Name:CLIFFORD
Middle Name:STANLEY
Last Name:GRAVES
Suffix:
Gender:M
Credentials:DMIN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3955 NEW YORK AVE
Mailing Address - Street 2:
Mailing Address - City:FAIR OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:95628-7405
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11344 COLOMA RD STE 250
Practice Address - Street 2:
Practice Address - City:GOLD RIVER
Practice Address - State:CA
Practice Address - Zip Code:95670-6300
Practice Address - Country:US
Practice Address - Phone:916-863-6002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2007-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34719106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist