Healthcare Provider Details

I. General information

NPI: 1932392537
Provider Name (Legal Business Name): GRAHAM PSHCHOLOGICAL CONSULTING AND RESTORATION, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2007
Last Update Date: 09/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9111 BROADWAY SUITE Q
MERRILLVILLE IN
46410-8122
US

IV. Provider business mailing address

5425 N PAULINA ST UNIT 2 NORTH
CHICAGO IL
60640-1139
US

V. Phone/Fax

Practice location:
  • Phone: 773-501-3557
  • Fax: 773-275-1710
Mailing address:
  • Phone: 773-501-3557
  • Fax: 773-275-1710

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number20042049
License Number StateIN

VIII. Authorized Official

Name: PATRICIA GRAHAM
Title or Position: OWNER
Credential: PSYD HSPP
Phone: 779-275-1710