Provider Demographics
NPI:1992900120
Name:GRAVELINE, ANGIE B (PT, DPT)
Entity type:Individual
Prefix:
First Name:ANGIE
Middle Name:B
Last Name:GRAVELINE
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:826 ORMOND CT
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92109-7330
Mailing Address - Country:US
Mailing Address - Phone:858-488-3483
Mailing Address - Fax:
Practice Address - Street 1:4510 VIEWRIDGE AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1637
Practice Address - Country:US
Practice Address - Phone:858-694-4905
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-18
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA274412251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic