MEDICARE: MR. SHAWN EDWARD GRAHAM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	CAC5036	ME
2	101YP2500X	Professional Counselor	CC5145	ME

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1154665578
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. SHAWN EDWARD GRAHAM

Provider Business Mailing Address
First Line	:	PO BOX 509
Second Line	:
City	:	PRESQUE ISLE
State	:	ME
Zip	:	04769-0509
Country	:	US
Telephone Number	:	207-764-6825
Fax Number	:	207-764-6077

Provider Business Practice Location Address
First Line	:	31 MARKET ST
Second Line	:
City	:	FORT KENT
State	:	ME
Zip	:	04743-1418
Country	:	US
Telephone Number	:	207-834-5430
Fax Number	:	207-834-2332

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/26/2012
Last Update Date	:	10/03/2019

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