Provider Demographics
NPI:1194019505
Name:GRAVES, MARQUITA LATOYA
Entity Type:Individual
Prefix:
First Name:MARQUITA
Middle Name:LATOYA
Last Name:GRAVES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:699 JOHN ST
Mailing Address - Street 2:UNIT 117
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98109-5053
Mailing Address - Country:US
Mailing Address - Phone:360-551-2662
Mailing Address - Fax:
Practice Address - Street 1:5001 STATESMAN DR
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75063-2414
Practice Address - Country:US
Practice Address - Phone:972-501-3195
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-02
Last Update Date:2011-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAP160089903225200000X
OR8722225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant