Provider Demographics
NPI:1508579822
Name:GRAVELY, MARY KATHERINE (MED)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KATHERINE
Last Name:GRAVELY
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2006 BREMO RD STE 101
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23226-2438
Mailing Address - Country:US
Mailing Address - Phone:804-918-1115
Mailing Address - Fax:
Practice Address - Street 1:2006 BREMO RD STE 101
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23226-2438
Practice Address - Country:US
Practice Address - Phone:804-918-1115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-02
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0704016336101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health