Basic Information
Provider Information | |||||||||
NPI: | 1154665578 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GRAHAM | ||||||||
FirstName: | SHAWN | ||||||||
MiddleName: | EDWARD | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 509 | ||||||||
Address2: |   | ||||||||
City: | PRESQUE ISLE | ||||||||
State: | ME | ||||||||
PostalCode: | 047690509 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2077646825 | ||||||||
FaxNumber: | 2077646077 | ||||||||
Practice Location | |||||||||
Address1: | 31 MARKET ST | ||||||||
Address2: |   | ||||||||
City: | FORT KENT | ||||||||
State: | ME | ||||||||
PostalCode: | 047431418 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2078345430 | ||||||||
FaxNumber: | 2078342332 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/26/2012 | ||||||||
LastUpdateDate: | 10/03/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | CAC5036 | ME | N |   | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YP2500X | CC5145 | ME | Y |   | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
ID | Type | State | Issuer | Description | 1740476159 | 05 | ME |   | MEDICAID |