Healthcare Provider Details

I. General information

NPI: 1972092401
Provider Name (Legal Business Name): KENNETH L. GRAVES
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/10/2018
Last Update Date: 10/06/2025
Certification Date: 10/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

680 PARK AVE W
MANSFIELD OH
44906-3706
US

IV. Provider business mailing address

680 PARK AVE W
MANSFIELD OH
44906-3706
US

V. Phone/Fax

Practice location:
  • Phone: 419-528-5993
  • Fax: 567-560-5483
Mailing address:
  • Phone: 419-528-5993
  • Fax: 567-560-5483

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberS.2512375
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number140444
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: