Provider Demographics
NPI:1164284071
Name:GRAHAM, SAMANTHA LYNN (DRPH, CBHCMS)
Entity Type:Individual
Prefix:DR
First Name:SAMANTHA
Middle Name:LYNN
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:DRPH, CBHCMS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 PRINCE PHILLIP DR
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092-1745
Mailing Address - Country:US
Mailing Address - Phone:904-990-4211
Mailing Address - Fax:
Practice Address - Street 1:9951 ATLANTIC BLVD STE 319
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32225-6577
Practice Address - Country:US
Practice Address - Phone:904-990-4211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-25
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCBHCM.0105764171M00000X
FLCBHCMS.0102666171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator