Healthcare Provider Details

I. General information

NPI: 1508167594
Provider Name (Legal Business Name): STEPHANIE RENE GRAHAM PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2010
Last Update Date: 08/26/2025
Certification Date: 08/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5401 QUARRY PARK RD
MADISON WI
53718-7901
US

IV. Provider business mailing address

702 N BLACKHAWK AVE SUITE 209
MADISON WI
53705-3357
US

V. Phone/Fax

Practice location:
  • Phone: 844-767-3769
  • Fax:
Mailing address:
  • Phone: 608-509-8060
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number2888-057
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: