Provider Demographics
NPI:1952879827
Name:GRAHAM, CRYSTAL SHAMAR (LCAS-A)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:SHAMAR
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:LCAS-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2513 LA DEARA CREST LN
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27105-3074
Mailing Address - Country:US
Mailing Address - Phone:336-920-1481
Mailing Address - Fax:
Practice Address - Street 1:284 EXECUTIVE PARK DR
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-1831
Practice Address - Country:US
Practice Address - Phone:704-939-1100
Practice Address - Fax:704-939-1173
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-08
Last Update Date:2022-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC25548833Medicaid