MEDICARE: SHONTAE L GRAHAM CC, MSP

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	101Y00000X	Counselor		CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	17773901	OTHER	CA	LA COUNTY VENDOR ID NUMBER

General Provider Information

NPI Number	:	1780177428
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHONTAE L GRAHAM CC, MSP

Provider Business Mailing Address
First Line	:	4261 SAN PEDRO PL # 409
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90011-2917
Country	:	US
Telephone Number	:	310-770-6749
Fax Number	:

Provider Business Practice Location Address
First Line	:	4261 SAN PEDRO PL
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90011-2917
Country	:	US
Telephone Number	:	310-770-6749
Fax Number	:

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

Provider Enumeration Date	:	06/07/2018
Last Update Date	:	06/07/2018

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