Provider Demographics
NPI:1093414567
Name:GRAVES, BRANDY MICHELLE
Entity type:Individual
Prefix:
First Name:BRANDY
Middle Name:MICHELLE
Last Name:GRAVES
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:PO BOX 488
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:WI
Mailing Address - Zip Code:53104-0488
Mailing Address - Country:US
Mailing Address - Phone:262-997-9411
Mailing Address - Fax:262-997-3844
Practice Address - Street 1:2900 ROOSEVELT RD
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53143-4642
Practice Address - Country:US
Practice Address - Phone:262-997-9411
Practice Address - Fax:262-997-3844
Is Sole Proprietor?:No
Enumeration Date:2023-02-23
Last Update Date:2025-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8436226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional