Provider Demographics
NPI:1467648030
Name:GRAVINA, LESLIE (PT)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:GRAVINA
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 1:2357 SEDGEWREN LOOP NE
Mailing Address - Street 2:
Mailing Address - City:LELAND
Mailing Address - State:NC
Mailing Address - Zip Code:28451-9679
Mailing Address - Country:US
Mailing Address - Phone:678-431-9828
Mailing Address - Fax:
Practice Address - Street 1:2357 SEDGEWREN LOOP NE
Practice Address - Street 2:
Practice Address - City:LELAND
Practice Address - State:NC
Practice Address - Zip Code:28451-9679
Practice Address - Country:US
Practice Address - Phone:678-431-9828
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-18
Last Update Date:2025-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT0090242251P0200X
NCP22346225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA536511322AMedicaid