1134356116 NPI number — KENT L GRAHAM MA, LPC, LCAS, CCS

Table of content: KENT L GRAHAM MA, LPC, LCAS, CCS (NPI 1134356116)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134356116 NPI number — KENT L GRAHAM MA, LPC, LCAS, CCS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRAHAM
Provider First Name:
KENT
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MA, LPC, LCAS, CCS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1134356116
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/14/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
101 IVERSON LANE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW BERN
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28562
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-330-6620
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2000 NEUSE BLVD
Provider Second Line Business Practice Location Address:
CROSSROADS, CAROLINAEAST MEDICAL CENTER
Provider Business Practice Location Address City Name:
NEW BERN
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28560
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
252-633-8215
Provider Business Practice Location Address Fax Number:
252-633-8198
Provider Enumeration Date:
06/17/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  743 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 101YP2500X , with the licence number: 4420 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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