Provider Demographics
NPI:1023316494
Name:GRAVELINE, TONY J (LADC)
Entity type:Individual
Prefix:
First Name:TONY
Middle Name:J
Last Name:GRAVELINE
Suffix:
Gender:M
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 724
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:VT
Mailing Address - Zip Code:05855
Mailing Address - Country:US
Mailing Address - Phone:802-334-6744
Mailing Address - Fax:
Practice Address - Street 1:181 CRAWFORD ROAD
Practice Address - Street 2:
Practice Address - City:DERBY
Practice Address - State:VT
Practice Address - Zip Code:05829
Practice Address - Country:US
Practice Address - Phone:802-334-6744
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-08
Last Update Date:2014-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0680101473101YM0800X
VT000526101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)