Healthcare Provider Details

I. General information

NPI: 1710611348
Provider Name (Legal Business Name): JOHN-NATHAN HOWARD GRAHAM LADAC, QCS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2022
Last Update Date: 07/16/2026
Certification Date: 07/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 FRECKLES CT
JOHNSON CITY TN
37601-1417
US

IV. Provider business mailing address

204 FRECKLES CT
JOHNSON CITY TN
37601-1417
US

V. Phone/Fax

Practice location:
  • Phone: 423-609-5672
  • Fax:
Mailing address:
  • Phone: 423-609-5672
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1579
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: