Healthcare Provider Details

I. General information

NPI: 1992129704
Provider Name (Legal Business Name): GARY LEE GRAHAM NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2014
Last Update Date: 01/09/2024
Certification Date: 05/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34290 FORD RD
WESTLAND MI
48185-3051
US

IV. Provider business mailing address

34290 FORD RD
WESTLAND MI
48185-3051
US

V. Phone/Fax

Practice location:
  • Phone: 734-324-8326
  • Fax:
Mailing address:
  • Phone: 734-324-8326
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number4704197715
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: