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General NPI Number Information
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NPI Number | 1699894766
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Entity Type | Individual
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Provider Name | JOHN ELLINGTON GRAHAM III MA, MSED
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Gender | Male
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Dates
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Enumeration Date | 03/28/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 300 FORT ZUMWALT SQ SUITE 107
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City | O FALLON
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State | MO
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Zip | 63366-3078
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Country | US
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Telephone | 636-980-4673
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Fax | 636-625-8284
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Provider Business Mailing Address
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Address Line | 13 POINTER CT
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City | LAKE ST LOUIS
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State | MO
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Zip | 63367-2017
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Country | US
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Telephone | 636-485-2900
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Fax | 636-625-8284
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 001763
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License Number State | MO
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