Healthcare Provider Details

I. General information

NPI: 1750844635
Provider Name (Legal Business Name): EBONY GRAHAM MA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2019
Last Update Date: 04/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 WESTBROOK RD
ESSEX CT
06426-1518
US

IV. Provider business mailing address

255 HEMPSTEAD ST
NEW LONDON CT
06320-6204
US

V. Phone/Fax

Practice location:
  • Phone: 860-767-0147
  • Fax: 860-767-0148
Mailing address:
  • Phone: 860-443-2896
  • Fax: 860-442-5909

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: