Healthcare Provider Details

I. General information

NPI: 1134627664
Provider Name (Legal Business Name): HEATHER MARIE GRAHAM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2018
Last Update Date: 06/16/2025
Certification Date: 06/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 N COUNTY FARM RD
WHEATON IL
60187-3977
US

IV. Provider business mailing address

1649 VICTORIA PARK CIRCLE
AURORA IL
60504
US

V. Phone/Fax

Practice location:
  • Phone: 630-682-7400
  • Fax:
Mailing address:
  • Phone: 630-973-8408
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number178.013299
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178.013299
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: