Provider Demographics
NPI:1801359203
Name:GRAVATT, CARRIE RAYE (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:RAYE
Last Name:GRAVATT
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 WINDFLOWER CT
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81001-1119
Mailing Address - Country:US
Mailing Address - Phone:719-250-1144
Mailing Address - Fax:
Practice Address - Street 1:3960 IVYWOOD LN
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81005-2567
Practice Address - Country:US
Practice Address - Phone:719-924-9850
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-11
Last Update Date:2019-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0001411235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist