Provider Demographics
NPI:1780716076
Name:GRAVES, THERESE DANIELLE (PT)
Entity type:Individual
Prefix:
First Name:THERESE
Middle Name:DANIELLE
Last Name:GRAVES
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9400 WILLIAMSBURG PLZ
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40222-5093
Mailing Address - Country:US
Mailing Address - Phone:502-412-4486
Mailing Address - Fax:502-412-4490
Practice Address - Street 1:9400 WILLIAMSBURG PLZ
Practice Address - Street 2:SUITE 100
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40222-5093
Practice Address - Country:US
Practice Address - Phone:502-412-4486
Practice Address - Fax:502-412-4490
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2013-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY001636225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYP00441671OtherRAILROAD MEDICARE
KY5024604Medicare PIN