Provider Demographics
NPI:1831226489
Name:GRAVES, MARK C (PT)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:C
Last Name:GRAVES
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:8823 PRODUCTION LN
Mailing Address - Street 2:
Mailing Address - City:OOLTEWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37363-6511
Mailing Address - Country:US
Mailing Address - Phone:423-238-7217
Mailing Address - Fax:423-954-7408
Practice Address - Street 1:870 N ELLINGTON PKWY
Practice Address - Street 2:
Practice Address - City:LEWISBURG
Practice Address - State:TN
Practice Address - Zip Code:37091-2271
Practice Address - Country:US
Practice Address - Phone:931-361-4023
Practice Address - Fax:931-361-4024
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2014-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN8892255A2300X
TN8683225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN8683OtherPHYSICAL THERAPY LICENSE