Provider Demographics
NPI:1508225699
Name:GRAHAM, DESHEA YVONNE
Entity Type:Individual
Prefix:
First Name:DESHEA
Middle Name:YVONNE
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:156 LEXIE LN
Mailing Address - Street 2:
Mailing Address - City:PALMYRA
Mailing Address - State:VA
Mailing Address - Zip Code:22963-2078
Mailing Address - Country:US
Mailing Address - Phone:703-475-6179
Mailing Address - Fax:
Practice Address - Street 1:1 BOARS HEAD LN
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22903-4681
Practice Address - Country:US
Practice Address - Phone:434-202-4155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-17
Last Update Date:2022-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0913181041C0700X
VA09040107881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00355940Medicaid
VA6776040OtherAETNA
VA697861OtherANTHEM BLUE CROSS BLUE SHIELD
NYWVE061OtherMEDICARE #
NY1285628552OtherAGENCY
VA14343049OtherCIGNA