Provider Demographics
NPI:1649633652
Name:HARGRAVE, JAMES MICHAEL SR (LCDC,CEAP)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:MICHAEL
Last Name:HARGRAVE
Suffix:SR
Gender:M
Credentials:LCDC,CEAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3608 MELODY LN
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-0884
Mailing Address - Country:US
Mailing Address - Phone:903-293-7485
Mailing Address - Fax:903-614-7100
Practice Address - Street 1:3608 MELODY LN
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-0884
Practice Address - Country:US
Practice Address - Phone:903-293-7485
Practice Address - Fax:903-614-7100
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-29
Last Update Date:2016-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX004160101Y00000X
TX10223101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor