Healthcare Provider Details

I. General information

NPI: 1255619474
Provider Name (Legal Business Name): ROXANN NOLE-GRAHAM M.S. NCC LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2011
Last Update Date: 07/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1141 CLAY AVE
SCRANTON PA
18510-1191
US

IV. Provider business mailing address

902 LONGVIEW TER
CLARKS SUMMIT PA
18411-8923
US

V. Phone/Fax

Practice location:
  • Phone: 570-963-2079
  • Fax:
Mailing address:
  • Phone: 570-586-9258
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberPCOO5940
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: