Healthcare Provider Details

I. General information

NPI: 1568618445
Provider Name (Legal Business Name): GINA MARIE GRAHAM PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2008
Last Update Date: 08/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 SW GAGE BLVD BLDG 2, MHC
TOPEKA KS
66622-0001
US

IV. Provider business mailing address

2200 SW GAGE BLVD BLDG 2, MHC
TOPEKA KS
66622-0001
US

V. Phone/Fax

Practice location:
  • Phone: 785-350-3111
  • Fax: 785-350-4471
Mailing address:
  • Phone: 785-350-3111
  • Fax: 785-350-4471

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: