Provider Demographics
NPI:1982653895
Name:GRAVES, STEPHANIE L (MA LPE)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:L
Last Name:GRAVES
Suffix:
Gender:F
Credentials:MA LPE
Other - Prefix:MS
Other - First Name:STEPHANIE
Other - Middle Name:
Other - Last Name:EDWARDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2500 RIKE DRIVE
Mailing Address - Street 2:
Mailing Address - City:PINE BLUFF
Mailing Address - State:AR
Mailing Address - Zip Code:71603
Mailing Address - Country:US
Mailing Address - Phone:870-534-1834
Mailing Address - Fax:870-534-5798
Practice Address - Street 1:301 N OAK ST
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:AR
Practice Address - Zip Code:72150
Practice Address - Country:US
Practice Address - Phone:870-942-5101
Practice Address - Fax:870-942-7123
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR0404E103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5Y016Medicare ID - Type Unspecified