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Individual
MRS. MANDY W GRAVITTE
Active
Individual
MRS. MANDY W GRAVITTE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
LCSW, LCAS-A
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
2324-A
NC
1041C0700X
Clinical Social Worker
Primary
C006569
NC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2853446
MEDICARE PTAN
NC
05
—
6007450
—
NC
Enumeration date
10/26/2009
Last updated
11/13/2012
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