Healthcare Provider Details

I. General information

NPI: 1326171950
Provider Name (Legal Business Name): HEATHER JEAN GRAVLEY MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: HEATHER JEAN NELSON BECK MS

II. Dates (important events)

Enumeration Date: 03/13/2007
Last Update Date: 03/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 2ND ST SE
MINOT ND
58701-3924
US

IV. Provider business mailing address

215 2ND ST SE
MINOT ND
58701-3924
US

V. Phone/Fax

Practice location:
  • Phone: 701-857-4410
  • Fax: 701-857-4413
Mailing address:
  • Phone: 701-857-4410
  • Fax: 701-857-4413

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number876
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: