Provider Demographics
NPI:1003396623
Name:GRAHAM, VANESSA WYCHE (PHD, MA, MSN)
Entity type:Individual
Prefix:MS
First Name:VANESSA
Middle Name:WYCHE
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:PHD, MA, MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4115 COLUMBIA RD STE 5 PMB 205
Mailing Address - Street 2:
Mailing Address - City:MARTINEZ
Mailing Address - State:GA
Mailing Address - Zip Code:30907-0405
Mailing Address - Country:US
Mailing Address - Phone:706-799-7972
Mailing Address - Fax:
Practice Address - Street 1:4115 COLUMBIA RD STE 5 PMB 205
Practice Address - Street 2:
Practice Address - City:MARTINEZ
Practice Address - State:GA
Practice Address - Zip Code:30907-0405
Practice Address - Country:US
Practice Address - Phone:706-799-7972
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-14
Last Update Date:2024-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN102766163W00000X
GAAPC004945101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No163W00000XNursing Service ProvidersRegistered Nurse