Provider Demographics
NPI:1962665406
Name:DEWBERRY GRAHAM LLC
Entity Type:Organization
Organization Name:DEWBERRY GRAHAM LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RONETTA
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:919-217-0061
Mailing Address - Street 1:6845 KNIGHTDALE BLVD
Mailing Address - Street 2:STE 104
Mailing Address - City:KNIGHTDALE
Mailing Address - State:NC
Mailing Address - Zip Code:27545-9651
Mailing Address - Country:US
Mailing Address - Phone:919-217-0061
Mailing Address - Fax:919-217-0069
Practice Address - Street 1:6845 KNIGHTDALE BLVD
Practice Address - Street 2:STE 104
Practice Address - City:KNIGHTDALE
Practice Address - State:NC
Practice Address - Zip Code:27545-9651
Practice Address - Country:US
Practice Address - Phone:919-217-0061
Practice Address - Fax:919-217-0069
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-03
Last Update Date:2015-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6006458Medicaid
NC5917583Medicaid
C409Medicare UPIN