Provider Demographics
NPI:1801366174
Name:DRAHAM, LEO JOHN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:LEO
Middle Name:JOHN
Last Name:DRAHAM
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 RAVENEL ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29205-2762
Mailing Address - Country:US
Mailing Address - Phone:610-955-5823
Mailing Address - Fax:
Practice Address - Street 1:115 ATRIUM WAY STE 221
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29223-6383
Practice Address - Country:US
Practice Address - Phone:803-699-8887
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-29
Last Update Date:2018-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1538103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical