=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437822301
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KENNETH GRAVES JR LICENSE MARRIAGE AND FAMILY THERAPIST
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/27/2021
-----------------------------------------------------
Last Update Date | 07/27/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1000 QUAIL ST STE 135
-----------------------------------------------------
City | NEWPORT BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92660-2719
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-397-2562
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1000 QUAIL ST STE 135
-----------------------------------------------------
City | NEWPORT BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92660-2719
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-397-2562
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/CFO
-----------------------------------------------------
Name | MR. KENNETH E GRAVES JR.
-----------------------------------------------------
Credential | MA, LMFT
-----------------------------------------------------
Telephone | 714-397-2562
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------