Provider Demographics
NPI:1821724592
Name:GRAVELY, MARGUERITE
Entity Type:Individual
Prefix:
First Name:MARGUERITE
Middle Name:
Last Name:GRAVELY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 SEAPORT BLVD
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02210-2499
Mailing Address - Country:US
Mailing Address - Phone:617-221-4689
Mailing Address - Fax:
Practice Address - Street 1:69 ALLEGHANY ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02120-3336
Practice Address - Country:US
Practice Address - Phone:857-308-3255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-26
Last Update Date:2022-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator