Provider Demographics
NPI:1629262514
Name:LESLIE J. GRAHAM, MSW, LISW-CP, LLC
Entity Type:Organization
Organization Name:LESLIE J. GRAHAM, MSW, LISW-CP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOTHERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:J
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:843-971-4001
Mailing Address - Street 1:222 W COLEMAN BLVD
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-3494
Mailing Address - Country:US
Mailing Address - Phone:843-971-4001
Mailing Address - Fax:843-416-8354
Practice Address - Street 1:222 W COLEMAN BLVD
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-3494
Practice Address - Country:US
Practice Address - Phone:843-971-4001
Practice Address - Fax:843-416-8354
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-04
Last Update Date:2007-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCLISW-CP 8517251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ77528Medicare UPIN