Provider Demographics
NPI:1356877245
Name:GRAHAM, AMANDA JEAN (MSBS, LCADC)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:JEAN
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:MSBS, LCADC
Other - Prefix:
Other - First Name:MANDY
Other - Middle Name:JEAN
Other - Last Name:GRAHAM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MSBS, LCADC
Mailing Address - Street 1:100 DIECKS DR
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-2443
Mailing Address - Country:US
Mailing Address - Phone:270-238-1485
Mailing Address - Fax:
Practice Address - Street 1:100 DIECKS DR
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-2443
Practice Address - Country:US
Practice Address - Phone:580-726-2452
Practice Address - Fax:580-726-2483
Is Sole Proprietor?:No
Enumeration Date:2017-05-11
Last Update Date:2024-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY291034101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)