Provider Demographics
NPI:1700967247
Name:GRAVES, SUZANNE THOMAS (MPT)
Entity type:Individual
Prefix:
First Name:SUZANNE
Middle Name:THOMAS
Last Name:GRAVES
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:MS
Other - First Name:SUZANNE
Other - Middle Name:THOMAS
Other - Last Name:GRAVES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPT
Mailing Address - Street 1:310 W 11TH ST
Mailing Address - Street 2:
Mailing Address - City:SILVER CITY
Mailing Address - State:NM
Mailing Address - Zip Code:88061-5113
Mailing Address - Country:US
Mailing Address - Phone:575-534-1187
Mailing Address - Fax:
Practice Address - Street 1:310 W 11TH ST
Practice Address - Street 2:
Practice Address - City:SILVER CITY
Practice Address - State:NM
Practice Address - Zip Code:88061-5113
Practice Address - Country:US
Practice Address - Phone:575-534-1187
Practice Address - Fax:575-534-1439
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2017-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2117225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM65139721Medicaid
NM65139721Medicaid