Provider Demographics
NPI:1619605623
Name:GRAVES, KENNETH L ((LMSW))
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:L
Last Name:GRAVES
Suffix:
Gender:M
Credentials:(LMSW)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:826 COLUMBUS AVE APT 11G
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10025-4506
Mailing Address - Country:US
Mailing Address - Phone:212-837-2711
Mailing Address - Fax:
Practice Address - Street 1:826 COLUMBUS AVE APT 11G
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10025-4506
Practice Address - Country:US
Practice Address - Phone:212-837-2711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-09
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY046572-01101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health