Healthcare Provider Details

I. General information

NPI: 1861323958
Provider Name (Legal Business Name): DANDRE LAWRENCE GRAHAM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2026
Last Update Date: 05/27/2026
Certification Date: 05/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

726 N GREENFIELD RD STE 110
GILBERT AZ
85234-5062
US

IV. Provider business mailing address

1235 W BASELINE RD APT 323
TEMPE AZ
85283-5949
US

V. Phone/Fax

Practice location:
  • Phone: 602-649-0248
  • Fax:
Mailing address:
  • Phone: 602-860-0420
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberD52235765
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: