Healthcare Provider Details

I. General information

NPI: 1508363623
Provider Name (Legal Business Name): JAMIE GRAVELLE MSW, LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2018
Last Update Date: 04/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

69 BRIGHAM ST
HUDSON MA
01749-2787
US

IV. Provider business mailing address

6 CHASE CIR
ASHLAND MA
01721-3910
US

V. Phone/Fax

Practice location:
  • Phone: 978-567-6250
  • Fax: 978-567-6285
Mailing address:
  • Phone: 508-596-4234
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number110739
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: