=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306213855
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHEILA GRAHAM CAC-AD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/31/2015
-----------------------------------------------------
Last Update Date | 08/31/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4659 LOGSDON DR
-----------------------------------------------------
City | ANNANDALE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22003-3564
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-773-3500
-----------------------------------------------------
Fax | 301-773-1170
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4659 LOGSDON DR
-----------------------------------------------------
City | ANNANDALE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22003-3564
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-773-3500
-----------------------------------------------------
Fax | 301-773-1170
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | AC1794
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------