Provider Demographics
NPI:1427089671
Name:GRAPES, KRISTIN ELIZABETH (PHD)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:ELIZABETH
Last Name:GRAPES
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2910 BRIARCLIFFE RD
Mailing Address - Street 2:SUITE 604-B
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27106-3176
Mailing Address - Country:US
Mailing Address - Phone:336-407-6764
Mailing Address - Fax:336-773-0332
Practice Address - Street 1:2910 BRIARCLIFF ROAD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106-3176
Practice Address - Country:US
Practice Address - Phone:336-407-6764
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2016-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC673103TA0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1582323OtherVALUE OPTIONS
NC6000520Medicaid
NC6114757OtherUNITED BEHAVIORAL HEALTH
NC03629OtherBLUE CROSS BLUE SHEILD
NCR40964Medicare UPIN
NC1582323OtherVALUE OPTIONS