Basic Information
| Provider Information | |||||||||
| NPI: | 1053382259 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRAVELY | ||||||||
| FirstName: | VONDA | ||||||||
| MiddleName: | K | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 124 MALLARD ST | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296014046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8642411040 | ||||||||
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| Practice Location | |||||||||
| Address1: | 250 DEWEY AVE | ||||||||
| Address2: | |||||||||
| City: | SPARTANBURG | ||||||||
| State: | SC | ||||||||
| PostalCode: | 293033009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8645850366 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/27/2006 | ||||||||
| LastUpdateDate: | 03/09/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 21107 | SC | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 5905213 | 05 | NC | MEDICAID | 211078 | 05 | SC | MEDICAID | C7069 | 01 | SC | MEDCOST | OTHER |