Healthcare Provider Details

I. General information

NPI: 1467200360
Provider Name (Legal Business Name): ANNA RENEA GRAVES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2024
Last Update Date: 08/05/2024
Certification Date: 08/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4700 GORDON DR
SIOUX CITY IA
51106-1911
US

IV. Provider business mailing address

4820 4TH AVE APT 207
SIOUX CITY IA
51106-3016
US

V. Phone/Fax

Practice location:
  • Phone: 712-318-3351
  • Fax:
Mailing address:
  • Phone: 712-202-8544
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number127129
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: