Provider Demographics
NPI:1780177428
Name:GRAHAM, SHONTAE L (CC, MSP)
Entity type:Individual
Prefix:
First Name:SHONTAE
Middle Name:L
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:CC, MSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4261 SAN PEDRO PL # 409
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90011-2917
Mailing Address - Country:US
Mailing Address - Phone:310-770-6749
Mailing Address - Fax:
Practice Address - Street 1:4261 SAN PEDRO PL
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90011-2917
Practice Address - Country:US
Practice Address - Phone:310-770-6749
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-07
Last Update Date:2018-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA17773901OtherLA COUNTY VENDOR ID NUMBER