Healthcare Provider Details

I. General information

NPI: 1518192772
Provider Name (Legal Business Name): VIRGINIA GRAHAM PHD, ATR-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2009
Last Update Date: 05/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

430 BRADDOCK AVE
DAYTONA BEACH FL
32118-4616
US

IV. Provider business mailing address

411 OCEAN SHORE BLVD
ORMOND BEACH FL
32176-5449
US

V. Phone/Fax

Practice location:
  • Phone: 386-258-1618
  • Fax: 386-253-4215
Mailing address:
  • Phone: 386-672-8492
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code221700000X
TaxonomyArt Therapist
License Number221700000X
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code221700000X
TaxonomyArt Therapist
License NumberVG14981
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: