MEDICARE: MR. CHARLES GRAHAM MSW

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	1041C0700X	Clinical Social Worker	44SC01338000	NJ

General Provider Information

NPI Number	:	1770665242
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CHARLES GRAHAM MSW

Provider Business Mailing Address
First Line	:	202 S ATLANTIC AVE
Second Line	:
City	:	HADDONFIELD
State	:	NJ
Zip	:	08033-3302
Country	:	US
Telephone Number	:	856-857-1656
Fax Number	:

Provider Business Practice Location Address
First Line	:	12000 LINCOLN DR W
Second Line	:	SUITE 407 PAVILIONS AT GREENTREE
City	:	MARLTON
State	:	NJ
Zip	:	08053-3402
Country	:	US
Telephone Number	:	856-985-3404
Fax Number	:	856-985-7847

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

Provider Enumeration Date	:	10/20/2006
Last Update Date	:	12/28/2007

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