Healthcare Provider Details

I. General information

NPI: 1164858239
Provider Name (Legal Business Name): CECILIA ANN GRAHAM LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2013
Last Update Date: 06/26/2023
Certification Date: 06/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

271 FT. RICHARDSON AVE BLDG 1007
GOODFELLOW AFB TX
76908
US

IV. Provider business mailing address

271 FT. RICHARDSON AVE BLDG 1007
GOODFELLOW AFB TX
76908
US

V. Phone/Fax

Practice location:
  • Phone: 325-654-3122
  • Fax: 325-654-5161
Mailing address:
  • Phone: 325-654-3122
  • Fax: 325-654-5161

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number106581
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-12572
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: