=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689097123
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GRETCHEN PETRIE GRAFF M.A., LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/03/2014
-----------------------------------------------------
Last Update Date | 01/21/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10536 AUTO MALL PKWY STE B
-----------------------------------------------------
City | DIBERVILLE
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39540-3742
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 985-260-1914
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 36108 VINSON RD
-----------------------------------------------------
City | PEARL RIVER
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70452-5802
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 985-260-1914
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 3016
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 6716
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------