Provider Demographics
NPI:1851079313
Name:GRAVITT, KRISTEN (CDCA)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:GRAVITT
Suffix:
Gender:F
Credentials:CDCA
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:
Other - Last Name:JONES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 212
Mailing Address - Street 2:
Mailing Address - City:XENIA
Mailing Address - State:OH
Mailing Address - Zip Code:45385-0212
Mailing Address - Country:US
Mailing Address - Phone:937-708-8348
Mailing Address - Fax:
Practice Address - Street 1:1087 W 2ND ST
Practice Address - Street 2:
Practice Address - City:XENIA
Practice Address - State:OH
Practice Address - Zip Code:45385-3713
Practice Address - Country:US
Practice Address - Phone:937-708-8348
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-06
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.184815101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)