MEDICARE: DEZNIQUE GRAHAM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	P019174	NC

General Provider Information

NPI Number	:	1447962246
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEZNIQUE GRAHAM

Provider Business Mailing Address
First Line	:	5046 GRAYS CREEK CHURCH RD
Second Line	:
City	:	HOPE MILLS
State	:	NC
Zip	:	28348-7812
Country	:	US
Telephone Number	:	910-493-3555
Fax Number	:	910-493-3520

Provider Business Practice Location Address
First Line	:	5046 GRAYS CREEK CHURCH RD
Second Line	:
City	:	HOPE MILLS
State	:	NC
Zip	:	28348-7812
Country	:	US
Telephone Number	:	910-493-3555
Fax Number	:	910-493-3520

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/23/2022
Last Update Date	:	02/16/2024

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