Provider Demographics
NPI:1508313628
Name:GRAVES, KWANDA LEE
Entity Type:Individual
Prefix:MISS
First Name:KWANDA
Middle Name:LEE
Last Name:GRAVES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 TEAL DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27127-6812
Mailing Address - Country:US
Mailing Address - Phone:336-918-2381
Mailing Address - Fax:
Practice Address - Street 1:4401 PROVIDENCE LANE
Practice Address - Street 2:SUITE 121
Practice Address - City:WINSTON-SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106
Practice Address - Country:US
Practice Address - Phone:336-896-1323
Practice Address - Fax:336-896-1327
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-07
Last Update Date:2016-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1598959660Medicaid