Provider Demographics
NPI:1982735700
Name:GRACIANO, MIGUEL JR
Entity Type:Individual
Prefix:
First Name:MIGUEL
Middle Name:
Last Name:GRACIANO
Suffix:JR
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 1:1507 BRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90033-1606
Mailing Address - Country:US
Mailing Address - Phone:323-887-1917
Mailing Address - Fax:323-887-1655
Practice Address - Street 1:2226 E RIO VERDE DR
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91791-2067
Practice Address - Country:US
Practice Address - Phone:626-332-1367
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor