Provider Demographics
NPI:1619509296
Name:GRAHAM, SUSANNE LISE (LMHC)
Entity Type:Individual
Prefix:
First Name:SUSANNE
Middle Name:LISE
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6509 OREGON CHICKADEE RD
Mailing Address - Street 2:
Mailing Address - City:WEEKI WACHEE
Mailing Address - State:FL
Mailing Address - Zip Code:34613-8353
Mailing Address - Country:US
Mailing Address - Phone:352-345-9267
Mailing Address - Fax:
Practice Address - Street 1:10051 COUNTRY RD
Practice Address - Street 2:
Practice Address - City:WEEKI WACHEE
Practice Address - State:FL
Practice Address - Zip Code:34613-5264
Practice Address - Country:US
Practice Address - Phone:352-345-9267
Practice Address - Fax:352-652-3656
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-11
Last Update Date:2023-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLLMHC17795101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty