MEDICARE: BRANDON LEWIS-GRAHAM MHS

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

General Provider Information

NPI Number	:	1962960351
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRANDON LEWIS-GRAHAM MHS

Provider Business Mailing Address
First Line	:	3201 KNIGHT ST APT 2206
Second Line	:
City	:	SHREVEPORT
State	:	LA
Zip	:	71105-2749
Country	:	US
Telephone Number	:	318-422-4209
Fax Number	:

Provider Business Practice Location Address
First Line	:	3201 KNIGHT ST APT 2206
Second Line	:
City	:	SHREVEPORT
State	:	LA
Zip	:	71105-2749
Country	:	US
Telephone Number	:	318-422-4209
Fax Number	:

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

Provider Enumeration Date	:	03/05/2019
Last Update Date	:	03/05/2019

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