Provider Demographics
NPI:1528471505
Name:GRAHAM, SAMANTHA (MSPC LAC)
Entity type:Individual
Prefix:MRS
First Name:SAMANTHA
Middle Name:
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:MSPC LAC
Other - Prefix:MISS
Other - First Name:SAMANTHA
Other - Middle Name:
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2060 W WHISPERING WIND DR
Mailing Address - Street 2:SUITE 274
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85085-2867
Mailing Address - Country:US
Mailing Address - Phone:623-879-7599
Mailing Address - Fax:
Practice Address - Street 1:2060 W WHISPERING WIND DR
Practice Address - Street 2:SUITE 274
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85085-2867
Practice Address - Country:US
Practice Address - Phone:623-879-7599
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-06
Last Update Date:2014-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-14476101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor