Doctor Name: | TONY J GRAVELINE |
NPI Number: | 1023316494 |
Entity Type Code: | Individual (1) |
Gender: | M |
Credentials: | LADC |
License Number: | 000526 |
Business Practice Address: | 181 Crawford Road Derby, VT - 05829 |
Business Phone Number: | 8023346744 |
Business Fax Number: | |
Mailing Address: | Po Box 724, NEWPORT |
State: | VT |
Postal Code: | 05855 |
Phone Number: | 8023346744 |
Fax Number: | |
NPI Enumeration Date: | 03/08/2011 |
NPI Last Update Date: | 09/05/2014 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 101YA0400X |
License Number: | 000526 |
Healthcare Provider Taxonomy: (Secondary) | N |
State: | VT |
Taxonomy Type: | Behavioral Health & Social Service Providers |
Taxonomy Classification: | Counselor |
Taxonomy Specialization: | Addiction (Substance Use Disorder) |
Taxonomy Definition: |