Healthcare Provider Details

I. General information

NPI: 1700791993
Provider Name (Legal Business Name): RAETONYA DAVETTE GRAHAM LISW-CP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

47 FISHERMAN LN
GREENVILLE SC
29615-5013
US

IV. Provider business mailing address

404 BRENNA LN
PIEDMONT SC
29673-8180
US

V. Phone/Fax

Practice location:
  • Phone: 855-390-6568
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number19194
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: