Healthcare Provider Details

I. General information

NPI: 1043519903
Provider Name (Legal Business Name): ALL'WYN DALE GRAHAM NCC LPC SAP ADC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/17/2011
Last Update Date: 12/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4011 MERIDIAN ST
NORMAL AL
35762-5312
US

IV. Provider business mailing address

2251 HELTON DR APT E5
FLORENCE AL
35630-1084
US

V. Phone/Fax

Practice location:
  • Phone: 256-372-4751
  • Fax: 256-372-5599
Mailing address:
  • Phone: 256-348-8131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number20238
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number524
License Number StateAL
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2942
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: