Provider Demographics
NPI:1912064239
Name:GRAVENESE, COURTNEY LEE (MS, RD)
Entity Type:Individual
Prefix:MS
First Name:COURTNEY
Middle Name:LEE
Last Name:GRAVENESE
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:92 HILLSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:VERONA
Mailing Address - State:NJ
Mailing Address - Zip Code:07044-1023
Mailing Address - Country:US
Mailing Address - Phone:646-373-3651
Mailing Address - Fax:
Practice Address - Street 1:460 BLOOMFIELD AVE
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07042-3582
Practice Address - Country:US
Practice Address - Phone:973-734-0780
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005045-1133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered