Healthcare Provider Details

I. General information

NPI: 1356877245
Provider Name (Legal Business Name): AMANDA JEAN GRAHAM MSBS, LCADC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MANDY JEAN GRAHAM MSBS, LCADC

II. Dates (important events)

Enumeration Date: 05/11/2017
Last Update Date: 03/10/2024
Certification Date: 03/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 DIECKS DR
ELIZABETHTOWN KY
42701-2443
US

IV. Provider business mailing address

100 DIECKS DR
ELIZABETHTOWN KY
42701-2443
US

V. Phone/Fax

Practice location:
  • Phone: 580-726-2452
  • Fax: 580-726-2483
Mailing address:
  • Phone: 270-238-1485
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number291034
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: