Provider Demographics
NPI:1295700789
Name:GRAVES GORRELL, LINDA M (LISW)
Entity type:Individual
Prefix:
First Name:LINDA
Middle Name:M
Last Name:GRAVES GORRELL
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:AMELIA
Mailing Address - State:OH
Mailing Address - Zip Code:45102-1993
Mailing Address - Country:US
Mailing Address - Phone:513-947-7000
Mailing Address - Fax:513-947-7222
Practice Address - Street 1:43 E MAIN ST
Practice Address - Street 2:
Practice Address - City:AMELIA
Practice Address - State:OH
Practice Address - Zip Code:45102-1993
Practice Address - Country:US
Practice Address - Phone:513-947-7000
Practice Address - Fax:513-947-7222
Is Sole Proprietor?:No
Enumeration Date:2006-02-20
Last Update Date:2009-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI0009237101YM0800X, 1041C0700X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHSW27841Medicare ID - Type UnspecifiedMEDICARE
SW27841Medicare UPIN