Provider Demographics
NPI:1235247628
Name:GRAVELY, MARSHALL GUILBERT (LCSW)
Entity Type:Individual
Prefix:MR
First Name:MARSHALL
Middle Name:GUILBERT
Last Name:GRAVELY
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:200 E 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28052-4358
Mailing Address - Country:US
Mailing Address - Phone:704-874-1904
Mailing Address - Fax:704-867-2134
Practice Address - Street 1:420 N SALISBURY ST
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:NC
Practice Address - Zip Code:27292-3548
Practice Address - Country:US
Practice Address - Phone:336-243-7475
Practice Address - Fax:336-249-6771
Is Sole Proprietor?:No
Enumeration Date:2006-08-27
Last Update Date:2019-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0024711041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC191052OtherMEDCOST
NC2327208OtherCIGNA
NC6003651Medicaid
NC1235247628OtherTRICARE
NC1235247628OtherCORPHEALTH
NC1235247628OtherUNITED BEHAVIORAL HEALTH
NC132MROtherBCBS
NC2327208OtherCIGNA