Provider Demographics
NPI:1770533044
Name:BURKE-GRAVETTER, DEBORAH ANN (LCSW)
Entity type:Individual
Prefix:MS
First Name:DEBORAH
Middle Name:ANN
Last Name:BURKE-GRAVETTER
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 1:30 HIGHVIEW CIR
Mailing Address - Street 2:
Mailing Address - City:BROCKPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14420-2637
Mailing Address - Country:US
Mailing Address - Phone:585-415-4913
Mailing Address - Fax:585-637-8096
Practice Address - Street 1:80 WEST AVE # 9
Practice Address - Street 2:
Practice Address - City:BROCKPORT
Practice Address - State:NY
Practice Address - Zip Code:14420-1322
Practice Address - Country:US
Practice Address - Phone:585-415-4913
Practice Address - Fax:585-637-8096
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-10
Last Update Date:2017-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR045000-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02717320Medicaid
NYP010045000OtherLCSW
NY02717320Medicaid