MEDICARE: MRS. PAULETTE GRAHAM LCSW

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
2	1041C0700X	Clinical Social Worker	1454-C	AR

General Provider Information

NPI Number	:	1891781449
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. PAULETTE GRAHAM LCSW

Provider Business Mailing Address
First Line	:	1815 PLEASANT GROVE ROAD
Second Line	:
City	:	JONESBORO
State	:	AR
Zip	:	72401
Country	:	US
Telephone Number	:	870-933-6886
Fax Number	:	870-933-9395

Provider Business Practice Location Address
First Line	:	2908 HAWKINS DR
Second Line	:
City	:	SEARCY
State	:	AR
Zip	:	72143-4802
Country	:	US
Telephone Number	:	501-203-0055
Fax Number	:	501-203-0060

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

Provider Enumeration Date	:	09/20/2005
Last Update Date	:	06/11/2019

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