Provider Demographics
NPI:1598193831
Name:REAVES, GRAHAM (MSOT)
Entity Type:Individual
Prefix:
First Name:GRAHAM
Middle Name:
Last Name:REAVES
Suffix:
Gender:M
Credentials:MSOT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 PEACHTREE VALLEY RD NE
Mailing Address - Street 2:APARTMENT 1727
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-1411
Mailing Address - Country:US
Mailing Address - Phone:706-676-2413
Mailing Address - Fax:
Practice Address - Street 1:1901 PHOENIX BLVD
Practice Address - Street 2:SUITE 120
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30349-5063
Practice Address - Country:US
Practice Address - Phone:404-355-0743
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-24
Last Update Date:2013-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA005790273Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273Y00000XHospital UnitsRehabilitation Unit