Basic Information
| Provider Information | |||||||||
| NPI: | 1629511704 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRAVES | ||||||||
| FirstName: | ELISE | ||||||||
| MiddleName: | |||||||||
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| Credential: | MA RADT1 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 27281 LAS RAMBLAS STE 140 | ||||||||
| Address2: | |||||||||
| City: | MISSION VIEJO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926916387 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9495400170 | ||||||||
| FaxNumber: | 9495400173 | ||||||||
| Practice Location | |||||||||
| Address1: | 27281 LAS RAMBLAS STE 140 | ||||||||
| Address2: | |||||||||
| City: | MISSION VIEJO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92691 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9495400170 | ||||||||
| FaxNumber: | 9495400173 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/22/2016 | ||||||||
| LastUpdateDate: | 11/27/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 1041C0700X | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 101YA0400X | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.