Provider Demographics
NPI:1306545850
Name:GRAHAM, SHAWNTAE
Entity type:Individual
Prefix:
First Name:SHAWNTAE
Middle Name:
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:345 BROADMOOR WAY
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-4290
Mailing Address - Country:US
Mailing Address - Phone:678-644-6751
Mailing Address - Fax:678-759-2696
Practice Address - Street 1:345 BROADMOOR WAY
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-4290
Practice Address - Country:US
Practice Address - Phone:678-644-6751
Practice Address - Fax:678-759-2696
Is Sole Proprietor?:No
Enumeration Date:2023-02-23
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003005071AMedicaid