Provider Demographics
NPI:1568536928
Name:GRAVELL, KATHRYN ELAINE (CCC,SLP)
Entity Type:Individual
Prefix:MS
First Name:KATHRYN
Middle Name:ELAINE
Last Name:GRAVELL
Suffix:
Gender:F
Credentials:CCC,SLP
Other - Prefix:
Other - First Name:KATHY
Other - Middle Name:
Other - Last Name:GRAVELL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA, CCC-SLP
Mailing Address - Street 1:101 N EDGEWOOD DR APT 2
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21740-6518
Mailing Address - Country:US
Mailing Address - Phone:678-471-2817
Mailing Address - Fax:
Practice Address - Street 1:101 N EDGEWOOD DR APT 2
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21740-6518
Practice Address - Country:US
Practice Address - Phone:678-471-2817
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTSLP-SP-LIC-4134235Z00000X
TNSP 0000004935235Z00000X
FLSA 9250235Z00000X
GASLP005728235Z00000X
MD08396235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GASLP005728OtherGA STATE SLP LICENSE #
GA044589267AMedicaid
MD08396OtherMD SLP LICENSE #
MT1568536928Medicaid
FL892578000Medicaid
MTSLP-SP-LIC-4134OtherMT SLP LINCENSE #
FLSA 9250OtherFL STATE SLP LICENSE #
TNSP 0000004935OtherTN STATE SLP LICENSE #