Provider Demographics
NPI:1275689416
Name:GRAVES, KENNETH JEROME (PHD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:JEROME
Last Name:GRAVES
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3551 ROGER BROOKE DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78234-4504
Mailing Address - Country:US
Mailing Address - Phone:210-916-6299
Mailing Address - Fax:
Practice Address - Street 1:1005 W JEFFERSON BLVD
Practice Address - Street 2:SUITE 205
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75208-5087
Practice Address - Country:US
Practice Address - Phone:214-916-4025
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-27
Last Update Date:2018-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX30557103TC2200X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0962334-01Medicaid