Provider Demographics
NPI:1083162481
Name:GRAVELIN, KATHLENE
Entity Type:Individual
Prefix:
First Name:KATHLENE
Middle Name:
Last Name:GRAVELIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KATHLENE
Other - Middle Name:
Other - Last Name:RUNYON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS
Mailing Address - Street 1:100 CAMPUS DR
Mailing Address - Street 2:SUITE 121
Mailing Address - City:SCARBOROUGH
Mailing Address - State:ME
Mailing Address - Zip Code:04074-7171
Mailing Address - Country:US
Mailing Address - Phone:207-396-7788
Mailing Address - Fax:
Practice Address - Street 1:100 CAMPUS DR
Practice Address - Street 2:SUITE 121
Practice Address - City:SCARBOROUGH
Practice Address - State:ME
Practice Address - Zip Code:04074-7171
Practice Address - Country:US
Practice Address - Phone:207-396-7788
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-14
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS