Healthcare Provider Details

I. General information

NPI: 1437822301
Provider Name (Legal Business Name): KENNETH GRAVES JR LICENSE MARRIAGE AND FAMILY THERAPIST
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2021
Last Update Date: 07/27/2021
Certification Date: 07/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 QUAIL ST STE 135
NEWPORT BEACH CA
92660-2719
US

IV. Provider business mailing address

1000 QUAIL ST STE 135
NEWPORT BEACH CA
92660-2719
US

V. Phone/Fax

Practice location:
  • Phone: 714-397-2562
  • Fax:
Mailing address:
  • Phone: 714-397-2562
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MR. KENNETH E GRAVES JR.
Title or Position: OWNER/CFO
Credential: MA, LMFT
Phone: 714-397-2562