1164429098 NPI number — MS. TERESA SHANKS GRAHAM R.PH., BCPP

Table of content: MS. TERESA SHANKS GRAHAM R.PH., BCPP (NPI 1164429098)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164429098 NPI number — MS. TERESA SHANKS GRAHAM R.PH., BCPP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRAHAM
Provider First Name:
TERESA
Provider Middle Name:
SHANKS
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
R.PH., BCPP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1164429098
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/30/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
101 SUMMERWOOD LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FOREST
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24551-1107
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
434-665-0483
Provider Business Mailing Address Fax Number:
434-947-2988

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
521 COLONY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MADISON HTS
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24572-2105
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
434-947-2081
Provider Business Practice Location Address Fax Number:
434-947-2998
Provider Enumeration Date:
07/07/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1835P1300X , with the licence number:  0202001802 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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