Provider Demographics
NPI:1376587774
Name:GRAHAM, SONDRA SHANTEL (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:SONDRA
Middle Name:SHANTEL
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MRS
Other - First Name:SONDRA
Other - Middle Name:SHANTEL
Other - Last Name:HICKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:1900 TEBEAU STREET
Mailing Address - Street 2:MAYO CLINIC HEALTH SYSTEM IN WAYCROSS
Mailing Address - City:WAYCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:31501
Mailing Address - Country:US
Mailing Address - Phone:912-338-6338
Mailing Address - Fax:912-338-6337
Practice Address - Street 1:1000 COMMISSIONER DR
Practice Address - Street 2:
Practice Address - City:DARIEN
Practice Address - State:GA
Practice Address - Zip Code:31305-9487
Practice Address - Country:US
Practice Address - Phone:912-437-9300
Practice Address - Fax:912-437-9481
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2013-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMSW0038471041C0700X
GACSW0049191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAMSW003847OtherSTATE LICENSE