Provider Demographics
NPI:1235982315
Name:GRAHAM, TANNETTA NICOLE TUCKER
Entity Type:Individual
Prefix:MRS
First Name:TANNETTA
Middle Name:NICOLE TUCKER
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:TANNETTA
Other - Middle Name:NICOLE
Other - Last Name:TUCKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2813 GLADE ASTER CT
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27604-5468
Mailing Address - Country:US
Mailing Address - Phone:919-706-9336
Mailing Address - Fax:
Practice Address - Street 1:1001 NAVAHO DR STE 150
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-7368
Practice Address - Country:US
Practice Address - Phone:919-706-9336
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-09
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health