Provider Demographics
NPI:1760642870
Name:GRAVELY, ROBIN JENNIFER (LCAS)
Entity Type:Individual
Prefix:MS
First Name:ROBIN
Middle Name:JENNIFER
Last Name:GRAVELY
Suffix:
Gender:F
Credentials:LCAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8219 BRYNMAR DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28270-1089
Mailing Address - Country:US
Mailing Address - Phone:704-442-8811
Mailing Address - Fax:
Practice Address - Street 1:8219 BRYNMAR DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28270-1089
Practice Address - Country:US
Practice Address - Phone:704-442-8811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-11
Last Update Date:2008-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1138101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)