Provider Demographics
NPI:1306121959
Name:GRAVES-WORNEY, GEVONNA ARDELL (LCASA)
Entity type:Individual
Prefix:MRS
First Name:GEVONNA
Middle Name:ARDELL
Last Name:GRAVES-WORNEY
Suffix:
Gender:F
Credentials:LCASA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5166 FARM HOUSE TRL
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-5394
Mailing Address - Country:US
Mailing Address - Phone:336-829-4277
Mailing Address - Fax:336-893-6324
Practice Address - Street 1:5166 FARM HOUSE TRL
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-5394
Practice Address - Country:US
Practice Address - Phone:336-829-4277
Practice Address - Fax:336-893-6324
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-14
Last Update Date:2021-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS-22009101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)