Provider Demographics
NPI:1972654671
Name:HARGRAVES, GRACIE ANN (EDD, LCPC)
Entity Type:Individual
Prefix:
First Name:GRACIE
Middle Name:ANN
Last Name:HARGRAVES
Suffix:
Gender:F
Credentials:EDD, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:523 E. 4TH S. ST.
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440
Mailing Address - Country:US
Mailing Address - Phone:208-359-0836
Mailing Address - Fax:
Practice Address - Street 1:2375 E SUNNYSIDE RD
Practice Address - Street 2:SUITE C
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-8280
Practice Address - Country:US
Practice Address - Phone:208-529-5777
Practice Address - Fax:208-529-5778
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC- 293101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health