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General NPI Number Information
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NPI Number | 1366951709
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Entity Type | Individual
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Provider Name | MANDILYN RENICE GRAHAM LCPC
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Gender | Female
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Dates
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Enumeration Date | 09/28/2017
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Last Update Date | 02/16/2023
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Provider Practice Location Address
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Address Line | 7770 PAINT CREEK DR
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City | YPSILANTI
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State | MI
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Zip | 48197-6139
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Country | US
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Telephone | 773-301-3640
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Fax |
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Provider Business Mailing Address
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Address Line | 17485 EASTGATE DR
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City | COUNTRY CLUB HILLS
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State | IL
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Zip | 60478-4640
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Country | US
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Telephone | 773-301-3640
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 6401222749
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 180.009581
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License Number State | IL
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