Provider Demographics
NPI:1922862390
Name:KEPHART, GRACELYN ROSE (CT)
Entity Type:Individual
Prefix:
First Name:GRACELYN
Middle Name:ROSE
Last Name:KEPHART
Suffix:
Gender:F
Credentials:CT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6239 MUDDY CREEK RD
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45233-4435
Mailing Address - Country:US
Mailing Address - Phone:937-779-0072
Mailing Address - Fax:
Practice Address - Street 1:11161 KENWOOD RD
Practice Address - Street 2:
Practice Address - City:BLUE ASH
Practice Address - State:OH
Practice Address - Zip Code:45242-1817
Practice Address - Country:US
Practice Address - Phone:513-744-4624
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-07
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.2405481-TRNE101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health