Provider Demographics
NPI:1316608037
Name:GRAHAM, LETICIA T (MSH, MPH, MSPC, LAPC)
Entity type:Individual
Prefix:MRS
First Name:LETICIA
Middle Name:T
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:MSH, MPH, MSPC, LAPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 LAKESHORE PT
Mailing Address - Street 2:
Mailing Address - City:SAINT MARYS
Mailing Address - State:GA
Mailing Address - Zip Code:31558-3843
Mailing Address - Country:US
Mailing Address - Phone:912-225-1120
Mailing Address - Fax:
Practice Address - Street 1:205 LAKESHORE PT
Practice Address - Street 2:
Practice Address - City:SAINT MARYS
Practice Address - State:GA
Practice Address - Zip Code:31558-3843
Practice Address - Country:US
Practice Address - Phone:912-225-1120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-05
Last Update Date:2022-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC008230101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional