Provider Demographics
NPI:1588300842
Name:GRAVES, KERRY
Entity type:Individual
Prefix:
First Name:KERRY
Middle Name:
Last Name:GRAVES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4626 W MARKET ST # 111
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27407-2974
Mailing Address - Country:US
Mailing Address - Phone:336-255-9958
Mailing Address - Fax:
Practice Address - Street 1:231 N SPRING ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27401-2231
Practice Address - Country:US
Practice Address - Phone:336-899-8800
Practice Address - Fax:336-899-8811
Is Sole Proprietor?:No
Enumeration Date:2022-05-10
Last Update Date:2022-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0174441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical