Provider Demographics
NPI:1265676423
Name:GRAVELINE, BETH CARLIN
Entity Type:Individual
Prefix:MS
First Name:BETH
Middle Name:CARLIN
Last Name:GRAVELINE
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 1:1234 DIVISADERO ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94115-3911
Mailing Address - Country:US
Mailing Address - Phone:415-921-7658
Mailing Address - Fax:415-921-2243
Practice Address - Street 1:1234 DIVISADERO ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94115-3911
Practice Address - Country:US
Practice Address - Phone:415-921-7658
Practice Address - Fax:415-921-2243
Is Sole Proprietor?:No
Enumeration Date:2009-04-30
Last Update Date:2009-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP-17296235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist