Provider Demographics
NPI:1952889776
Name:GRAVLEY, MONIQUE CELESTE (PTA)
Entity Type:Individual
Prefix:
First Name:MONIQUE
Middle Name:CELESTE
Last Name:GRAVLEY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:MONIQUE
Other - Middle Name:CELESTE
Other - Last Name:TABONE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:1133 S 300 E
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:UT
Mailing Address - Zip Code:84653-5649
Mailing Address - Country:US
Mailing Address - Phone:801-960-5515
Mailing Address - Fax:
Practice Address - Street 1:1133 S 300 E
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:UT
Practice Address - Zip Code:84653-5649
Practice Address - Country:US
Practice Address - Phone:801-960-5515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-02
Last Update Date:2018-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5212737-2402225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant