Provider Demographics
NPI:1457894552
Name:GRAVES, DWAYNE (CRM)
Entity Type:Individual
Prefix:
First Name:DWAYNE
Middle Name:
Last Name:GRAVES
Suffix:
Gender:M
Credentials:CRM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3878 BEVERLY AVE NE
Mailing Address - Street 2:BUILDING H SUITE 5
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97305-1394
Mailing Address - Country:US
Mailing Address - Phone:503-399-0670
Mailing Address - Fax:503-399-0655
Practice Address - Street 1:3878 BEVERLY AVE NE
Practice Address - Street 2:BUILDING H SUITE 5
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97305-1394
Practice Address - Country:US
Practice Address - Phone:503-399-0670
Practice Address - Fax:503-399-0655
Is Sole Proprietor?:No
Enumeration Date:2016-11-22
Last Update Date:2016-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR16-CRM-083101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)