Provider Demographics
NPI:1386239168
Name:GRAVELY, MATTHEW (CDCA)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:GRAVELY
Suffix:
Gender:M
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 CROWNE POINT PL
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45241-5427
Mailing Address - Country:US
Mailing Address - Phone:513-743-7628
Mailing Address - Fax:513-737-1107
Practice Address - Street 1:36 N DETROIT ST
Practice Address - Street 2:
Practice Address - City:XENIA
Practice Address - State:OH
Practice Address - Zip Code:45385-2909
Practice Address - Country:US
Practice Address - Phone:937-610-4673
Practice Address - Fax:513-737-1107
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-04
Last Update Date:2023-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 106S00000X
OHCDCA.181860101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician