MEDICARE: MS. SANDRA DECOURSEY GRAHAM MS, LPC

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	101YP2500X	Professional Counselor	LPC-13806	AZ

General Provider Information

NPI Number	:	1790050284
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SANDRA DECOURSEY GRAHAM MS, LPC

Provider Business Mailing Address
First Line	:	PO BOX 20045
Second Line	:
City	:	WICKENBURG
State	:	AZ
Zip	:	85358-5045
Country	:	US
Telephone Number	:	928-232-9195
Fax Number	:

Provider Business Practice Location Address
First Line	:	4545 N 36TH ST STE 102
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85018-3473
Country	:	US
Telephone Number	:	928-232-9195
Fax Number	:

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

Provider Enumeration Date	:	03/15/2012
Last Update Date	:	03/15/2012

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