Healthcare Provider Details

I. General information

NPI: 1831680636
Provider Name (Legal Business Name): LAUREN GRAHAM LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2018
Last Update Date: 05/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

323 N DIVISION ST
POWELL WY
82435-2207
US

IV. Provider business mailing address

PO BOX 270
POWELL WY
82435-0270
US

V. Phone/Fax

Practice location:
  • Phone: 307-250-0645
  • Fax: 888-247-7592
Mailing address:
  • Phone: 307-250-0645
  • Fax: 888-247-7592

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-838
License Number StateWY
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License NumberLCSW-838
License Number StateWY

VIII. Authorized Official

Name: LAUREN ALINE GRAHAM
Title or Position: OWNER
Credential: LCSW
Phone: 307-250-0645