Healthcare Provider Details

I. General information

NPI: 1629421672
Provider Name (Legal Business Name): BRENDA WILSON-GRAHAM MAMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2016
Last Update Date: 07/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3700 W KILGORE AVE
MUNCIE IN
47304-4810
US

IV. Provider business mailing address

5109 W WESTKNOLL CT
MUNCIE IN
47304-5039
US

V. Phone/Fax

Practice location:
  • Phone: 765-289-5437
  • Fax:
Mailing address:
  • Phone: 765-228-8970
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number0000000A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: