Provider Demographics
NPI:1487052007
Name:GRAVISS, TARA MARIE (EXPRESSIVE ARTS)
Entity type:Individual
Prefix:MS
First Name:TARA
Middle Name:MARIE
Last Name:GRAVISS
Suffix:
Gender:F
Credentials:EXPRESSIVE ARTS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4661 35TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92116-3537
Mailing Address - Country:US
Mailing Address - Phone:619-962-9853
Mailing Address - Fax:
Practice Address - Street 1:4661 35TH ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92116-3537
Practice Address - Country:US
Practice Address - Phone:619-962-9853
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-13
Last Update Date:2014-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA$$$$$$$$$OtherSSN