Provider Demographics
NPI:1902885981
Name:GRAGG, HEATHER DAWN (MPT)
Entity Type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:DAWN
Last Name:GRAGG
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:MISS
Other - First Name:HEATHER
Other - Middle Name:DAWN
Other - Last Name:GERLACH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPT
Mailing Address - Street 1:PO BOX 987
Mailing Address - Street 2:
Mailing Address - City:SUMMERSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26651-0987
Mailing Address - Country:US
Mailing Address - Phone:304-872-7498
Mailing Address - Fax:304-872-8144
Practice Address - Street 1:207 MERCHANTS WALK
Practice Address - Street 2:
Practice Address - City:SUMMERSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26651
Practice Address - Country:US
Practice Address - Phone:304-872-7498
Practice Address - Fax:304-872-8144
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810003510Medicaid