Provider Demographics
NPI:1710785761
Name:GRAHAM, SHANETAL (LCSWA)
Entity type:Individual
Prefix:
First Name:SHANETAL
Middle Name:
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:565 BLACK MAPLE DR
Mailing Address - Street 2:
Mailing Address - City:KANNAPOLIS
Mailing Address - State:NC
Mailing Address - Zip Code:28081-5880
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2908 AUDREY DR
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-7268
Practice Address - Country:US
Practice Address - Phone:704-412-1814
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-05
Last Update Date:2025-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0189241041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical