Provider Demographics
NPI:1730227893
Name:GRAVLEY, MICHELLE ANN (PSYD)
Entity type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:ANN
Last Name:GRAVLEY
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2881 BUSINESS PARK CT STE 150
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128-9020
Mailing Address - Country:US
Mailing Address - Phone:702-508-2112
Mailing Address - Fax:702-965-4587
Practice Address - Street 1:2881 BUSINESS PARK CT STE 150
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-9020
Practice Address - Country:US
Practice Address - Phone:702-508-2112
Practice Address - Fax:702-965-4587
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2017-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPY0381103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002602018Medicaid