Healthcare Provider Details

I. General information

NPI: 1518057421
Provider Name (Legal Business Name): GARY CLAYTON GRAHAM LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 07/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2603 W WACKERLY ST
MIDLAND MI
48640
US

IV. Provider business mailing address

809 E OAKRIDGE CT
MIDLAND MI
48640-8373
US

V. Phone/Fax

Practice location:
  • Phone: 989-631-2320
  • Fax: 989-631-9903
Mailing address:
  • Phone: 989-631-2320
  • Fax: 989-631-9903

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6801035003
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: