Provider Demographics
NPI:1962876250
Name:GRAHAM, CHASTITY SHERMAINE (MS)
Entity type:Individual
Prefix:MS
First Name:CHASTITY
Middle Name:SHERMAINE
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3456 SAINT HELENS DR
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71108-5351
Mailing Address - Country:US
Mailing Address - Phone:318-946-4152
Mailing Address - Fax:
Practice Address - Street 1:2620 CENTENARY BLVD STE 312
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71104
Practice Address - Country:US
Practice Address - Phone:318-681-9935
Practice Address - Fax:318-681-9938
Is Sole Proprietor?:No
Enumeration Date:2015-11-24
Last Update Date:2018-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA101YM0800X
171M00000X
LA1962876250171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health