Provider Demographics
NPI:1073037420
Name:GRAHAM, SAMANTHA (LMHC)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 70
Mailing Address - Street 2:
Mailing Address - City:LE MARS
Mailing Address - State:IA
Mailing Address - Zip Code:51031-0070
Mailing Address - Country:US
Mailing Address - Phone:712-546-4624
Mailing Address - Fax:712-546-9395
Practice Address - Street 1:180 10TH ST SE STE 201
Practice Address - Street 2:
Practice Address - City:LE MARS
Practice Address - State:IA
Practice Address - Zip Code:51031-2557
Practice Address - Country:US
Practice Address - Phone:712-546-4624
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-27
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA088121101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1184706566Medicaid
IA1497930572Medicaid