Healthcare Provider Details

I. General information

NPI: 1700439924
Provider Name (Legal Business Name): NICHOLAS JOHN GRAHAM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2019
Last Update Date: 04/30/2026
Certification Date: 04/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

217 W 3RD ST
PERRYSBURG OH
43551-1414
US

IV. Provider business mailing address

2026 GREEN VALLEY DR
TOLEDO OH
43614-3220
US

V. Phone/Fax

Practice location:
  • Phone: 419-806-6663
  • Fax:
Mailing address:
  • Phone: 419-309-1008
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberC.2103211
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: