Provider Demographics
NPI:1164000394
Name:GRAVES, CHARLES BEVAUN
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:BEVAUN
Last Name:GRAVES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:C. BEVAUN
Other - Middle Name:
Other - Last Name:GRAVES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:8844 WINCHESTER RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46819-2254
Mailing Address - Country:US
Mailing Address - Phone:260-440-9864
Mailing Address - Fax:
Practice Address - Street 1:2500 E STATE BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-4728
Practice Address - Country:US
Practice Address - Phone:260-426-5431
Practice Address - Fax:260-421-1029
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-30
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34009069A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical