Provider Demographics
NPI:1619300688
Name:SMITH GRAVES, KAMEKA TAYANA
Entity Type:Individual
Prefix:
First Name:KAMEKA
Middle Name:TAYANA
Last Name:SMITH GRAVES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KAMEKA
Other - Middle Name:TAYANA
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2901 MEADOW LARK DR
Mailing Address - Street 2:MAIL STOP P-535
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-2711
Mailing Address - Country:US
Mailing Address - Phone:619-806-6852
Mailing Address - Fax:
Practice Address - Street 1:2901 MEADOW LARK DR
Practice Address - Street 2:MAIL STOP P-535
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-2711
Practice Address - Country:US
Practice Address - Phone:619-806-6852
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-14
Last Update Date:2021-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALPCC3076101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health