Provider Demographics
NPI:1174979173
Name:GRAHAM, KERTRINA
Entity type:Individual
Prefix:
First Name:KERTRINA
Middle Name:
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:412 WILDWOOD DR
Mailing Address - Street 2:
Mailing Address - City:QUINBY
Mailing Address - State:SC
Mailing Address - Zip Code:29506-7240
Mailing Address - Country:US
Mailing Address - Phone:843-610-0717
Mailing Address - Fax:
Practice Address - Street 1:412 WILDWOOD DR
Practice Address - Street 2:
Practice Address - City:QUINBY
Practice Address - State:SC
Practice Address - Zip Code:29506-7240
Practice Address - Country:US
Practice Address - Phone:843-610-0717
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-09
Last Update Date:2016-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC87001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical