Provider Demographics
NPI:1336657055
Name:GRAHAM, AMANDA LEIGH (EDD)
Entity Type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:LEIGH
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1453 BIG HILL RD
Mailing Address - Street 2:
Mailing Address - City:PENNINGTON GAP
Mailing Address - State:VA
Mailing Address - Zip Code:24277-8133
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1453 BIG HILL RD
Practice Address - Street 2:
Practice Address - City:PENNINGTON GAP
Practice Address - State:VA
Practice Address - Zip Code:24277-8133
Practice Address - Country:US
Practice Address - Phone:276-393-9771
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-16
Last Update Date:2018-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701005028101YM0800X
VA0710102168101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VANAOtherNA