Provider Demographics
NPI:1649640988
Name:GRAVIN, ANTHONY STUART (DPT)
Entity type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:STUART
Last Name:GRAVIN
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1419 W GEORGE ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-4103
Mailing Address - Country:US
Mailing Address - Phone:916-505-3101
Mailing Address - Fax:
Practice Address - Street 1:412 W 31ST ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616-3116
Practice Address - Country:US
Practice Address - Phone:312-225-3119
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-29
Last Update Date:2015-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.021832225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist