Provider Demographics
NPI:1689498396
Name:GRAVELLE, KRISTA (LMHCA)
Entity type:Individual
Prefix:
First Name:KRISTA
Middle Name:
Last Name:GRAVELLE
Suffix:
Gender:F
Credentials:LMHCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21284 SUNRISE PL
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98273-8517
Mailing Address - Country:US
Mailing Address - Phone:360-708-7106
Mailing Address - Fax:
Practice Address - Street 1:21284 SUNRISE PL
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98273-8517
Practice Address - Country:US
Practice Address - Phone:360-708-7106
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-09
Last Update Date:2024-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMC61589384101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health