Healthcare Provider Details

I. General information

NPI: 1437828852
Provider Name (Legal Business Name): KATIE GRAHAM CADTP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2021
Last Update Date: 07/18/2024
Certification Date: 07/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 W CREST ST STE 100
ESCONDIDO CA
92025-1735
US

IV. Provider business mailing address

221 W CREST ST STE 100
ESCONDIDO CA
92025-1735
US

V. Phone/Fax

Practice location:
  • Phone: 760-744-3672
  • Fax:
Mailing address:
  • Phone: 760-744-3672
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number18613
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: