Provider Demographics
NPI:1396271441
Name:GRAVES, ROLAND JR (LMHC)
Entity type:Individual
Prefix:
First Name:ROLAND
Middle Name:
Last Name:GRAVES
Suffix:JR
Gender:M
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2691 STATE ROUTE 9 STE 204
Mailing Address - Street 2:
Mailing Address - City:MALTA
Mailing Address - State:NY
Mailing Address - Zip Code:12020-4319
Mailing Address - Country:US
Mailing Address - Phone:518-309-2192
Mailing Address - Fax:
Practice Address - Street 1:2691 STATE ROUTE 9 STE 204
Practice Address - Street 2:
Practice Address - City:MALTA
Practice Address - State:NY
Practice Address - Zip Code:12020-4319
Practice Address - Country:US
Practice Address - Phone:518-309-2192
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-11
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
NY009187101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1396271441Medicaid