Basic Information
| Provider Information | |||||||||
| NPI: | 1205303658 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRAVINO | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | A. | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LAC-COUNSELOR | ||||||||
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| Mailing Information | |||||||||
| Address1: | 204 BOONTEN AVE | ||||||||
| Address2: | |||||||||
| City: | KINNELON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 074053231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9738300559 | ||||||||
| FaxNumber: | 8478595885 | ||||||||
| Practice Location | |||||||||
| Address1: | 1055 PARSIPPANY BLVD | ||||||||
| Address2: | |||||||||
| City: | PARSIPPANY | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070541230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7329822888 | ||||||||
| FaxNumber: | 8478595885 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2018 | ||||||||
| LastUpdateDate: | 12/25/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/25/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 37AC00433400 | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.