Healthcare Provider Details

I. General information

NPI: 1033888227
Provider Name (Legal Business Name): DEBRA GRAHAM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2021
Last Update Date: 09/10/2021
Certification Date: 09/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4950 W 23RD ST STE 1
ERIE PA
16506-5803
US

IV. Provider business mailing address

4950 W 23RD ST STE 1
ERIE PA
16506-5803
US

V. Phone/Fax

Practice location:
  • Phone: 814-459-2755
  • Fax:
Mailing address:
  • Phone: 814-459-2755
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberSW135413
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: