Provider Demographics
NPI:1245732262
Name:GRAVELY, BETHANY L
Entity type:Individual
Prefix:
First Name:BETHANY
Middle Name:L
Last Name:GRAVELY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:324 T B STANLEY HWY STE BANDC
Mailing Address - Street 2:
Mailing Address - City:BASSETT
Mailing Address - State:VA
Mailing Address - Zip Code:24055-6108
Mailing Address - Country:US
Mailing Address - Phone:276-638-0787
Mailing Address - Fax:276-629-2695
Practice Address - Street 1:324 T B STANLEY HWY STE BANDC
Practice Address - Street 2:
Practice Address - City:BASSETT
Practice Address - State:VA
Practice Address - Zip Code:24055-6108
Practice Address - Country:US
Practice Address - Phone:276-638-0787
Practice Address - Fax:276-629-2695
Is Sole Proprietor?:No
Enumeration Date:2018-03-06
Last Update Date:2024-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040103931041C0700X
WVDP009452741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV36-4567127OtherLIFE STRATEGIES
VA1093891335Medicaid