Provider Demographics
NPI:1639470743
Name:MICHELLE GRAVLEY, P.C.
Entity Type:Organization
Organization Name:MICHELLE GRAVLEY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAVLEY
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:702-212-3008
Mailing Address - Street 1:2445 FIRE MESA ST
Mailing Address - Street 2:SUITE 190
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128-9014
Mailing Address - Country:US
Mailing Address - Phone:702-212-3008
Mailing Address - Fax:702-933-3064
Practice Address - Street 1:2445 FIRE MESA ST
Practice Address - Street 2:SUITE 190
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-9014
Practice Address - Country:US
Practice Address - Phone:702-212-3008
Practice Address - Fax:702-933-3064
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-04
Last Update Date:2010-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPY0381251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002602018Medicaid