Provider Demographics
NPI:1215018312
Name:GRAVELLE, LYNNELL MARIE (PT)
Entity Type:Individual
Prefix:
First Name:LYNNELL
Middle Name:MARIE
Last Name:GRAVELLE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 COMMONS LOOP
Mailing Address - Street 2:STE 100
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-1904
Mailing Address - Country:US
Mailing Address - Phone:406-261-8311
Mailing Address - Fax:
Practice Address - Street 1:175 COMMONS LOOP STE 100
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-1904
Practice Address - Country:US
Practice Address - Phone:406-261-8311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2019-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1315225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT3400102Medicaid
MT3400102Medicaid