Provider Demographics
NPI:1730415894
Name:GRAVITTE, MANDY W (LCSW, LCAS-A)
Entity type:Individual
Prefix:MRS
First Name:MANDY
Middle Name:W
Last Name:GRAVITTE
Suffix:
Gender:F
Credentials:LCSW, LCAS-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DOBSON
Mailing Address - State:NC
Mailing Address - Zip Code:27017-8593
Mailing Address - Country:US
Mailing Address - Phone:336-356-2600
Mailing Address - Fax:336-356-2601
Practice Address - Street 1:140 FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:MOUNT AIRY
Practice Address - State:NC
Practice Address - Zip Code:27030-4502
Practice Address - Country:US
Practice Address - Phone:336-755-2085
Practice Address - Fax:336-755-2086
Is Sole Proprietor?:No
Enumeration Date:2009-10-26
Last Update Date:2012-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0065691041C0700X
NC2324-A101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6007450Medicaid
NC2853446OtherMEDICARE PTAN