Provider Demographics
NPI:1104402650
Name:GRAVELY, LAQUISHA
Entity type:Individual
Prefix:
First Name:LAQUISHA
Middle Name:
Last Name:GRAVELY
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 1:101 E 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:RAEFORD
Mailing Address - State:NC
Mailing Address - Zip Code:28376-2233
Mailing Address - Country:US
Mailing Address - Phone:803-446-6661
Mailing Address - Fax:
Practice Address - Street 1:902 S REILLY RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28314-1825
Practice Address - Country:US
Practice Address - Phone:910-491-6356
Practice Address - Fax:910-491-8128
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-23
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X
NCA18128101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional