Provider Demographics
NPI:1952879827
Name:GRAHAM, CRYSTAL SHAMAR (LCAS)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:SHAMAR
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:LCAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8025 N POINT BLVD STE 283
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27106-3860
Mailing Address - Country:US
Mailing Address - Phone:336-920-1481
Mailing Address - Fax:336-245-1804
Practice Address - Street 1:8025 N POINT BLVD STE 283
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106-3860
Practice Address - Country:US
Practice Address - Phone:336-842-3396
Practice Address - Fax:336-245-1804
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-08
Last Update Date:2024-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1235876988Medicaid
NC1952879827Medicaid
NC25548833Medicaid