Provider Demographics
NPI:1205318490
Name:GRAVES, TERRA RENEE (LCSW)
Entity type:Individual
Prefix:MRS
First Name:TERRA
Middle Name:RENEE
Last Name:GRAVES
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 TABITHA LN
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MO
Mailing Address - Zip Code:63620-9123
Mailing Address - Country:US
Mailing Address - Phone:573-579-4573
Mailing Address - Fax:
Practice Address - Street 1:1 SOUTHTOWNE DR
Practice Address - Street 2:
Practice Address - City:POTOSI
Practice Address - State:MO
Practice Address - Zip Code:63664-5729
Practice Address - Country:US
Practice Address - Phone:573-438-9355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-04
Last Update Date:2018-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20170363481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical