Provider Demographics
NPI:1225199680
Name:GRAVES, JOHANNA RUTH (PT)
Entity Type:Individual
Prefix:MRS
First Name:JOHANNA
Middle Name:RUTH
Last Name:GRAVES
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 1:300 W LEMON ST
Mailing Address - Street 2:
Mailing Address - City:LITITZ
Mailing Address - State:PA
Mailing Address - Zip Code:17543-2398
Mailing Address - Country:US
Mailing Address - Phone:717-625-6140
Mailing Address - Fax:
Practice Address - Street 1:2760 CENTURY BOULEVARD
Practice Address - Street 2:
Practice Address - City:WYOMISSING
Practice Address - State:PA
Practice Address - Zip Code:19610
Practice Address - Country:US
Practice Address - Phone:610-406-4237
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2019-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY028249-1225100000X
PAPT022545225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
269654YENFMedicare PIN