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NPI Code Detail

MEDICARE: BONITA A GRAHAM

MEDICARE: BONITA A 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
1101Y00000XCounselor
2101YA0400XAddiction (Substance Use Disorder) Counselor
3101YA0400XAddiction (Substance Use Disorder) CounselorLCAS-24918NC
4101YM0800XMental Health Counselor
5101YP2500XProfessional CounselorA17557NC

General Provider Information

NPI Number : 1720732464
Entity Type Code : Individual
Provider Name (Legal Business Name) : BONITA A GRAHAM
Provider Business Mailing Address
First Line : 284 EXECUTIVE PARK DR STE 100
Second Line :
City : CONCORD
State : NC
Zip : 28025-1833
Country : US
Telephone Number : 704-939-1100
Fax Number : 704-939-1173
Provider Business Practice Location Address
First Line : 616 COLONNADE DR
Second Line :
City : CHARLOTTE
State : NC
Zip : 28205-6827
Country : US
Telephone Number : 704-273-3942
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 02/11/2022
Last Update Date : 04/07/2023

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Directions to “ BONITA A GRAHAM ” Practice Location

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