Healthcare Provider Details

I. General information

NPI: 1730181447
Provider Name (Legal Business Name): SAMUEL LEE GRAHAM PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/12/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 73RD ST
WINDSOR HEIGHTS IA
50311-1321
US

IV. Provider business mailing address

1000 73RD ST
WINDSOR HEIGHTS IA
50311-1321
US

V. Phone/Fax

Practice location:
  • Phone: 515-222-1175
  • Fax: 515-222-0953
Mailing address:
  • Phone: 515-222-1175
  • Fax: 515-222-0953

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number435/160
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: