Provider Demographics
NPI:1396561981
Name:GRAVES, KENNETH ALONZO (CSAC)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:ALONZO
Last Name:GRAVES
Suffix:
Gender:M
Credentials:CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2908 NIVRAM RD
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23805-2637
Mailing Address - Country:US
Mailing Address - Phone:804-590-8295
Mailing Address - Fax:
Practice Address - Street 1:2908 NIVRAM RD
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23805-2637
Practice Address - Country:US
Practice Address - Phone:804-590-8295
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-27
Last Update Date:2024-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0710102565101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)