Provider Demographics
NPI:1558821694
Name:GRAHAM, BRITTANY (MSW, LCSW)
Entity Type:Individual
Prefix:
First Name:BRITTANY
Middle Name:
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12400 BIELEFELD LN
Mailing Address - Street 2:
Mailing Address - City:BLACK JACK
Mailing Address - State:MO
Mailing Address - Zip Code:63033-4254
Mailing Address - Country:US
Mailing Address - Phone:618-616-7228
Mailing Address - Fax:
Practice Address - Street 1:13317 COUNTY HIGHWAY 12
Practice Address - Street 2:
Practice Address - City:VENEDY
Practice Address - State:IL
Practice Address - Zip Code:62214-1103
Practice Address - Country:US
Practice Address - Phone:618-317-1537
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-24
Last Update Date:2019-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0179841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical