MEDICARE: TESSA CAROLEEN GRAVANTE OTR/L

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	OTP-OT-LIC-7786	MT

General Provider Information

NPI Number	:	1790292415
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TESSA CAROLEEN GRAVANTE OTR/L

Provider Business Mailing Address
First Line	:	3031 S RUSSELL ST STE B
Second Line	:
City	:	MISSOULA
State	:	MT
Zip	:	59801-8523
Country	:	US
Telephone Number	:	406-396-4130
Fax Number	:

Provider Business Practice Location Address
First Line	:	3031 S RUSSELL ST STE B
Second Line	:
City	:	MISSOULA
State	:	MT
Zip	:	59801-8523
Country	:	US
Telephone Number	:	406-396-4130
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/03/2018
Last Update Date	:	01/21/2026

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