Healthcare Provider Details

I. General information

NPI: 1912848243
Provider Name (Legal Business Name): TABITHA GRAVIUS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2026
Last Update Date: 04/02/2026
Certification Date: 04/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7616 13TH AVE
BROOKLYN NY
11228-2412
US

IV. Provider business mailing address

177 AVENUE Z
BROOKLYN NY
11214-6909
US

V. Phone/Fax

Practice location:
  • Phone: 718-630-5100
  • Fax:
Mailing address:
  • Phone: 732-318-1367
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: