Provider Demographics
NPI:1992963516
Name:GRAVIL, MARY PAT (PTA)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:PAT
Last Name:GRAVIL
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1885 WRIGHT LN
Mailing Address - Street 2:
Mailing Address - City:BONNIEVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42713-7437
Mailing Address - Country:US
Mailing Address - Phone:502-592-4458
Mailing Address - Fax:
Practice Address - Street 1:1885 WRIGHT LN
Practice Address - Street 2:
Practice Address - City:BONNIEVILLE
Practice Address - State:KY
Practice Address - Zip Code:42713-7437
Practice Address - Country:US
Practice Address - Phone:502-592-4458
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-30
Last Update Date:2008-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY000036225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant