Provider Demographics
NPI:1255770640
Name:GRAVELY, DANE MATTHEW (PTA)
Entity type:Individual
Prefix:MR
First Name:DANE
Middle Name:MATTHEW
Last Name:GRAVELY
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1880 COLUMBUS DR
Mailing Address - Street 2:
Mailing Address - City:BASSETT
Mailing Address - State:VA
Mailing Address - Zip Code:24055-5389
Mailing Address - Country:US
Mailing Address - Phone:276-629-4279
Mailing Address - Fax:
Practice Address - Street 1:1880 COLUMBUS DR
Practice Address - Street 2:
Practice Address - City:BASSETT
Practice Address - State:VA
Practice Address - Zip Code:24055-5389
Practice Address - Country:US
Practice Address - Phone:276-629-4279
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-18
Last Update Date:2013-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306000674225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant