Provider Demographics
NPI:1548746605
Name:GRAHAM, TIFFANY MICHELLE (MA, LCMHC-A, LCAS-A)
Entity type:Individual
Prefix:MRS
First Name:TIFFANY
Middle Name:MICHELLE
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:MA, LCMHC-A, 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:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3545 WHITEHALL PARK DR STE 300
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28273-4179
Practice Address - Country:US
Practice Address - Phone:980-302-8850
Practice Address - Fax:704-316-8118
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-12
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS-21224101YA0400X
NCA16081101YP2500X
NC16081101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional