Provider Demographics
NPI:1831789296
Name:GRAVERSEN, MORTEN
Entity type:Individual
Prefix:
First Name:MORTEN
Middle Name:
Last Name:GRAVERSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:671 AVENIDA CARMEL
Mailing Address - Street 2:
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324-1367
Mailing Address - Country:US
Mailing Address - Phone:510-364-1277
Mailing Address - Fax:
Practice Address - Street 1:1850 N RIVERSIDE AVE STE 240
Practice Address - Street 2:
Practice Address - City:RIALTO
Practice Address - State:CA
Practice Address - Zip Code:92376-8082
Practice Address - Country:US
Practice Address - Phone:909-258-2220
Practice Address - Fax:909-258-2102
Is Sole Proprietor?:No
Enumeration Date:2021-01-20
Last Update Date:2024-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT299762225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist