Provider Demographics
NPI:1629800750
Name:GRAVERAN RODRIGUEZ, GRETTEL
Entity type:Individual
Prefix:
First Name:GRETTEL
Middle Name:
Last Name:GRAVERAN RODRIGUEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 COLONIAL AVE
Mailing Address - Street 2:
Mailing Address - City:LEHIGH ACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33971-5934
Mailing Address - Country:US
Mailing Address - Phone:239-980-5502
Mailing Address - Fax:239-236-1370
Practice Address - Street 1:1900 COLONIAL AVE
Practice Address - Street 2:
Practice Address - City:LEHIGH ACRES
Practice Address - State:FL
Practice Address - Zip Code:33971-5934
Practice Address - Country:US
Practice Address - Phone:239-980-5502
Practice Address - Fax:239-236-1370
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-16
Last Update Date:2024-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty