Provider Demographics
NPI:1366510349
Name:GRAVES, TAMI LISA (PT)
Entity type:Individual
Prefix:
First Name:TAMI
Middle Name:LISA
Last Name:GRAVES
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:TAMI
Other - Middle Name:LISA
Other - Last Name:LUNDMARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:24014 W RENWICK RD STE F
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60544-8708
Mailing Address - Country:US
Mailing Address - Phone:800-974-4378
Mailing Address - Fax:630-515-1536
Practice Address - Street 1:315 S ONEIDA AVE STE 102
Practice Address - Street 2:
Practice Address - City:RHINELANDER
Practice Address - State:WI
Practice Address - Zip Code:54501-3422
Practice Address - Country:US
Practice Address - Phone:800-974-4378
Practice Address - Fax:630-515-1536
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2749024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40101500Medicaid
330098018Medicare ID - Type Unspecified