Provider Demographics
NPI:1043823396
Name:GRAHAM, KETWAN KAREEM
Entity Type:Individual
Prefix:
First Name:KETWAN
Middle Name:KAREEM
Last Name:GRAHAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:507 WEST AVE
Mailing Address - Street 2:
Mailing Address - City:TROUTMAN
Mailing Address - State:NC
Mailing Address - Zip Code:28166-8619
Mailing Address - Country:US
Mailing Address - Phone:704-746-2420
Mailing Address - Fax:
Practice Address - Street 1:474 N CENTER ST
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28677-4022
Practice Address - Country:US
Practice Address - Phone:704-873-3491
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-26
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0131261041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical