Provider Demographics
NPI:1407979404
Name:GRAVANO, TAMARA NANCY (PT, DPT, GCS, CEEAA)
Entity Type:Individual
Prefix:DR
First Name:TAMARA
Middle Name:NANCY
Last Name:GRAVANO
Suffix:
Gender:F
Credentials:PT, DPT, GCS, CEEAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2847 5TH AVE
Mailing Address - Street 2:MARSHALL UNIVERSITY SCHOOL OF PHYSICAL THERAPY,
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25702-1435
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2847 5TH AVE
Practice Address - Street 2:MARSHALL UNIVERSITY SCHOOL OF PHYSICAL THERAPY,
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25702-1435
Practice Address - Country:US
Practice Address - Phone:304-696-5616
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2014-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT 20800225100000X
LA07435R2251G0304X
WVPT 0029392251G0304X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NPI 1407979404Medicare PIN