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General NPI Number Information
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NPI Number | 1174800791
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Entity Type | Organization
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Legal Business Name | ETHAN A GRAHAM PHD PSYCHOLOGIST PLLC
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Dates
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Enumeration Date | 11/10/2011
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Last Update Date | 11/10/2011
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Provider Practice Location Address
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Address Line | 330 WEST 58TH STREET SUITE 405
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City | NEW YORK
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State | NY
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Zip | 10019-1820
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Country | US
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Telephone | 718-702-2437
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Fax |
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Provider Business Mailing Address
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Address Line | 330 WEST 58TH STREET SUITE 405
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City | NEW YORK
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State | NY
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Zip | 10019-1820
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Country | US
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Telephone | 718-702-2437
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Fax |
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Authorized Official
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Title or Position | PSYCHOLOGIST
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Name | ETHAN A GRAHAM
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Credential | PH.D.
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Telephone | 718-702-2437
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 018415
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License Number State | NY
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