Provider Demographics
NPI:1639683402
Name:GRAHAM, SHANNON M (LMSW)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:M
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 PARK CREEK DR
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29605-4270
Mailing Address - Country:US
Mailing Address - Phone:864-299-1600
Mailing Address - Fax:
Practice Address - Street 1:41 PARK CREEK DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4270
Practice Address - Country:US
Practice Address - Phone:864-299-1600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-30
Last Update Date:2018-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY097934104100000X
SC12300104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker