MEDICARE: MRS. TANNETTA NICOLE TUCKER 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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1235982315
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. TANNETTA NICOLE TUCKER GRAHAM

Provider Business Mailing Address
First Line	:	2813 GLADE ASTER CT
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27604-5468
Country	:	US
Telephone Number	:	919-706-9336
Fax Number	:

Provider Business Practice Location Address
First Line	:	1001 NAVAHO DR STE 150
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27609-7368
Country	:	US
Telephone Number	:	919-706-9336
Fax Number	:

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

Provider Enumeration Date	:	04/09/2024
Last Update Date	:	04/09/2024

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