Provider Demographics
NPI:1437822301
Name:KENNETH GRAVES JR LICENSE MARRIAGE AND FAMILY THERAPIST
Entity Type:Organization
Organization Name:KENNETH GRAVES JR LICENSE MARRIAGE AND FAMILY THERAPIST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:E
Authorized Official - Last Name:GRAVES
Authorized Official - Suffix:JR
Authorized Official - Credentials:MA, LMFT
Authorized Official - Phone:714-397-2562
Mailing Address - Street 1:1000 QUAIL ST STE 135
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-2719
Mailing Address - Country:US
Mailing Address - Phone:714-397-2562
Mailing Address - Fax:
Practice Address - Street 1:1000 QUAIL ST STE 135
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-2719
Practice Address - Country:US
Practice Address - Phone:714-397-2562
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-27
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)