Healthcare Provider Details

I. General information

NPI: 1356204416
Provider Name (Legal Business Name): GEORGIA GRAVEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2025
Last Update Date: 12/05/2025
Certification Date: 12/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1976 NW PENNY LN
MCMINNVILLE OR
97128-6672
US

IV. Provider business mailing address

1976 NW PENNY LN
MCMINNVILLE OR
97128-6672
US

V. Phone/Fax

Practice location:
  • Phone: 503-435-7604
  • Fax:
Mailing address:
  • Phone: 503-435-7604
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number248916298
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: