Provider Demographics
NPI:1154665578
Name:GRAHAM, SHAWN EDWARD
Entity Type:Individual
Prefix:MR
First Name:SHAWN
Middle Name:EDWARD
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:PO BOX 509
Mailing Address - Street 2:
Mailing Address - City:PRESQUE ISLE
Mailing Address - State:ME
Mailing Address - Zip Code:04769-0509
Mailing Address - Country:US
Mailing Address - Phone:207-764-6825
Mailing Address - Fax:207-764-6077
Practice Address - Street 1:31 MARKET ST
Practice Address - Street 2:
Practice Address - City:FORT KENT
Practice Address - State:ME
Practice Address - Zip Code:04743-1418
Practice Address - Country:US
Practice Address - Phone:207-834-5430
Practice Address - Fax:207-834-2332
Is Sole Proprietor?:No
Enumeration Date:2012-11-26
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECAC5036101YA0400X
MECC5145101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1740476159Medicaid