Provider Demographics
NPI:1720143878
Name:GRAYBEAL, KENDRA CHURCH (MA, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:KENDRA
Middle Name:CHURCH
Last Name:GRAYBEAL
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5624 IDLEWILD RD
Mailing Address - Street 2:
Mailing Address - City:FLEETWOOD
Mailing Address - State:NC
Mailing Address - Zip Code:28626-9421
Mailing Address - Country:US
Mailing Address - Phone:336-877-1322
Mailing Address - Fax:336-877-1322
Practice Address - Street 1:5624 IDLEWILD RD
Practice Address - Street 2:
Practice Address - City:FLEETWOOD
Practice Address - State:NC
Practice Address - Zip Code:28626-9421
Practice Address - Country:US
Practice Address - Phone:336-877-1322
Practice Address - Fax:336-877-1322
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3616235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7401092Medicaid