=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801506910
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KATHRYN MARY GRAHAM PHD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/29/2022
-----------------------------------------------------
Last Update Date | 11/29/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 125 W 72ND ST RM 4R
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10023-3278
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-972-5671
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7 BUCKMINSTER RD
-----------------------------------------------------
City | ROCKVILLE CENTRE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11570-1203
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-282-4750
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | P119343
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------