Provider Demographics
NPI:1740889872
Name:GRAHAM, TANDREA (MSW)
Entity type:Individual
Prefix:
First Name:TANDREA
Middle Name:
Last Name:GRAHAM
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3550 WESTBRIAR LN
Mailing Address - Street 2:
Mailing Address - City:NORTH DINWIDDIE
Mailing Address - State:VA
Mailing Address - Zip Code:23803-8422
Mailing Address - Country:US
Mailing Address - Phone:804-605-6146
Mailing Address - Fax:
Practice Address - Street 1:628 OLD WAGNER RD
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23805-9319
Practice Address - Country:US
Practice Address - Phone:804-605-6146
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-20
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA3442172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker