Healthcare Provider Details

I. General information

NPI: 1437074408
Provider Name (Legal Business Name): LILLIE GRAHAM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2026
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11607 SOUTHFORK AVE BLDG B
BATON ROUGE LA
70816-5220
US

IV. Provider business mailing address

260 S 18TH ST
BATON ROUGE LA
70802-3933
US

V. Phone/Fax

Practice location:
  • Phone: 225-439-5432
  • Fax:
Mailing address:
  • Phone: 225-439-5432
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: