Provider Demographics
NPI:1780162008
Name:DAMON GRAHAM JR
Entity type:Organization
Organization Name:DAMON GRAHAM JR
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DAMON
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:JR
Authorized Official - Credentials:LCSW, MPA, MS
Authorized Official - Phone:229-224-0655
Mailing Address - Street 1:635 MYRON HART RD
Mailing Address - Street 2:
Mailing Address - City:COOLIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:31738-2143
Mailing Address - Country:US
Mailing Address - Phone:229-224-0655
Mailing Address - Fax:229-941-5865
Practice Address - Street 1:635 MYRON HART RD
Practice Address - Street 2:
Practice Address - City:COOLIDGE
Practice Address - State:GA
Practice Address - Zip Code:31738-2143
Practice Address - Country:US
Practice Address - Phone:229-224-0655
Practice Address - Fax:229-941-5865
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-30
Last Update Date:2019-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0057671041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty