Provider Demographics
NPI:1457892705
Name:PETGRAVE, DANNEL KARL (PHD)
Entity Type:Individual
Prefix:
First Name:DANNEL
Middle Name:KARL
Last Name:PETGRAVE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5722 CABIN CREEK RD
Mailing Address - Street 2:
Mailing Address - City:DAWES
Mailing Address - State:WV
Mailing Address - Zip Code:25054-7700
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5722 CABIN CREEK RD
Practice Address - Street 2:
Practice Address - City:DAWES
Practice Address - State:WV
Practice Address - Zip Code:25054
Practice Address - Country:US
Practice Address - Phone:304-734-2040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-19
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1243103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical