Healthcare Provider Details

I. General information

NPI: 1003396623
Provider Name (Legal Business Name): VANESSA WYCHE GRAHAM PHD, MSN, RN, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2018
Last Update Date: 06/04/2026
Certification Date: 06/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4451 WASHINGTON RD, STE 90 PMB 205
EVANS GA
30809
US

IV. Provider business mailing address

4451 WASHINGTON RD, STE 90 PMB 205
EVANS GA
30809
US

V. Phone/Fax

Practice location:
  • Phone: 706-799-7972
  • Fax:
Mailing address:
  • Phone: 706-799-7972
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLPC015606
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN102766
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: