Provider Demographics
NPI:1912140161
Name:GRAVES, BRUCE L
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:L
Last Name:GRAVES
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 1:2100 MANCHESTER RD
Mailing Address - Street 2:SUITE 900
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60187-4579
Mailing Address - Country:US
Mailing Address - Phone:630-926-3658
Mailing Address - Fax:
Practice Address - Street 1:2100 MANCHESTER RD
Practice Address - Street 2:SUITE 900
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60187-4579
Practice Address - Country:US
Practice Address - Phone:630-926-3658
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-16
Last Update Date:2010-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180-007300101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional