Provider Demographics
NPI:1447031182
Name:FRALEY, KENNETH III (QMHP-A, CSAC-S)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:FRALEY
Suffix:III
Gender:M
Credentials:QMHP-A, CSAC-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1773 CHASE POINTE CIR APT 527
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23454-7046
Mailing Address - Country:US
Mailing Address - Phone:843-319-1228
Mailing Address - Fax:
Practice Address - Street 1:2790 GODWIN BLVD STE 200
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434-8151
Practice Address - Country:US
Practice Address - Phone:866-934-7450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-09
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0709025201101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)