Healthcare Provider Details

I. General information

NPI: 1427664176
Provider Name (Legal Business Name): NICOLE GRAHAM PHD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2020
Last Update Date: 12/02/2024
Certification Date: 12/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 SE 7TH ST STE 705
FORT LAUDERDALE FL
33301-3469
US

IV. Provider business mailing address

12 SE 7TH ST STE 705
FORT LAUDERDALE FL
33301-3469
US

V. Phone/Fax

Practice location:
  • Phone: 954-365-5366
  • Fax:
Mailing address:
  • Phone: 954-365-5366
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. NICOLE GRAHAM
Title or Position: PRESIDENT
Credential: PHD
Phone: 954-365-5366