Provider Demographics
NPI:1558894915
Name:GRAVES, WILLARD TYRON
Entity Type:Individual
Prefix:
First Name:WILLARD
Middle Name:TYRON
Last Name:GRAVES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:275 13TH ST NE
Mailing Address - Street 2:1102
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-3694
Mailing Address - Country:US
Mailing Address - Phone:404-483-2191
Mailing Address - Fax:
Practice Address - Street 1:275 13TH ST NE
Practice Address - Street 2:1102
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-3694
Practice Address - Country:US
Practice Address - Phone:404-483-2191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-04
Last Update Date:2017-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA3451225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist