Provider Demographics
NPI:1255967410
Name:GRAVESANDE, CADISHA ALEXA (LMFT)
Entity type:Individual
Prefix:
First Name:CADISHA
Middle Name:ALEXA
Last Name:GRAVESANDE
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 E FOOTHILL BLVD STE 102
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91006-2361
Mailing Address - Country:US
Mailing Address - Phone:626-701-4249
Mailing Address - Fax:626-737-6034
Practice Address - Street 1:10532 ACACIA ST STE B4
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-5455
Practice Address - Country:US
Practice Address - Phone:909-325-3766
Practice Address - Fax:626-737-6034
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-19
Last Update Date:2020-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA117966106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA117966OtherBBS