Healthcare Provider Details

I. General information

NPI: 1114739968
Provider Name (Legal Business Name): COLIN GRAHAM LSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/20/2025
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 CAPITOL MALL STE 2350
SACRAMENTO CA
95814-4760
US

IV. Provider business mailing address

931 W LELAND AVE APT 402
CHICAGO IL
60640-6611
US

V. Phone/Fax

Practice location:
  • Phone: 312-775-2045
  • Fax:
Mailing address:
  • Phone: 517-214-7403
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.031683
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number39210
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: