MEDICARE: STACEY LYNN GRAVES MA, LCPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	BBH-LCPC-LIC-18899	MT

General Provider Information

NPI Number	:	1821523580
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACEY LYNN GRAVES MA, LCPC

Provider Business Mailing Address
First Line	:	PO BOX 7874
Second Line	:
City	:	MISSOULA
State	:	MT
Zip	:	59807-7874
Country	:	US
Telephone Number	:	406-690-7753
Fax Number	:

Provider Business Practice Location Address
First Line	:	913 SW HIGGINS AVE STE 202
Second Line	:
City	:	MISSOULA
State	:	MT
Zip	:	59803-1423
Country	:	US
Telephone Number	:	406-690-7753
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/01/2017
Last Update Date	:	08/31/2020

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