Healthcare Provider Details

I. General information

NPI: 1063303352
Provider Name (Legal Business Name): DEMYIA GRAHAM NCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2025
Last Update Date: 07/14/2025
Certification Date: 07/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

805 N BEECH ST # 2
TALLULAH LA
71282-3809
US

IV. Provider business mailing address

308 MANSION ST
PORT GIBSON MS
39150-2220
US

V. Phone/Fax

Practice location:
  • Phone: 318-493-5147
  • Fax: 318-493-5148
Mailing address:
  • Phone: 601-320-3765
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: