Provider Demographics
NPI:1902414006
Name:GRAVES, MISHA (PHD)
Entity Type:Individual
Prefix:
First Name:MISHA
Middle Name:
Last Name:GRAVES
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1311 S RECHTER CT
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-6173
Mailing Address - Country:US
Mailing Address - Phone:812-369-5704
Mailing Address - Fax:
Practice Address - Street 1:482 S LANDMARK AVE
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-5000
Practice Address - Country:US
Practice Address - Phone:812-333-8474
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-15
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool