Basic Information
Provider Information | |||||||||
NPI: | 1245732262 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GRAVELY | ||||||||
FirstName: | BETHANY | ||||||||
MiddleName: | L | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 118 12TH STREET | ||||||||
Address2: |   | ||||||||
City: | PRINCETON | ||||||||
State: | WV | ||||||||
PostalCode: | 247409040 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3044315168 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1333 SOUTHVIEW DR | ||||||||
Address2: |   | ||||||||
City: | BLUEFIELD | ||||||||
State: | WV | ||||||||
PostalCode: | 24701 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3043279205 | ||||||||
FaxNumber: | 3043279210 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/06/2018 | ||||||||
LastUpdateDate: | 11/20/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | DP00945274 | WV | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 0904010393 | VA | N |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
ID | Type | State | Issuer | Description | 36-4567127 | 01 | WV | LIFE STRATEGIES | OTHER | 1093891335 | 05 | VA |   | MEDICAID |