Healthcare Provider Details

I. General information

NPI: 1104698604
Provider Name (Legal Business Name): JAMES ANDREW GRAHAM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2023
Last Update Date: 10/27/2023
Certification Date: 10/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2075 W BEAVER RD # 520
TROY MI
48084-3480
US

IV. Provider business mailing address

2075 W BEAVER RD # 520
TROY MI
48084-3480
US

V. Phone/Fax

Practice location:
  • Phone: 248-646-6659
  • Fax: 248-642-8645
Mailing address:
  • Phone: 248-646-6659
  • Fax: 248-642-8645

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6362009793
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: