Provider Demographics
NPI:1316439334
Name:GRAVATT, GABRIEL GORDON (PTA)
Entity type:Individual
Prefix:
First Name:GABRIEL
Middle Name:GORDON
Last Name:GRAVATT
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1750 LINDA LN
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37803-5536
Mailing Address - Country:US
Mailing Address - Phone:865-406-0781
Mailing Address - Fax:
Practice Address - Street 1:1750 LINDA LN
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37803-5536
Practice Address - Country:US
Practice Address - Phone:865-406-0781
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-05
Last Update Date:2018-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN6641225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant