Healthcare Provider Details

I. General information

NPI: 1912448440
Provider Name (Legal Business Name): TAYMARA GRAVES CDCA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/16/2017
Last Update Date: 03/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

680 PARK AVE W 680 PARK AVE WEST
MANSFIELD OH
44906-3706
US

IV. Provider business mailing address

680 PARK AVE W 680 PARK AVE WEST
MANSFIELD OH
44906-3706
US

V. Phone/Fax

Practice location:
  • Phone: 419-528-5993
  • Fax: 567-560-5486
Mailing address:
  • Phone: 419-528-5993
  • Fax: 567-560-5486

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number040424
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: