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General NPI Number Information
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NPI Number | 1932392537
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Entity Type | Organization
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Legal Business Name | GRAHAM PSHCHOLOGICAL CONSULTING AND RESTORATION, INC
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Dates
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Enumeration Date | 08/27/2007
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Last Update Date | 09/13/2007
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Provider Practice Location Address
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Address Line | 9111 BROADWAY SUITE Q
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City | MERRILLVILLE
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State | IN
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Zip | 46410-8122
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Country | US
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Telephone | 773-501-3557
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Fax | 773-275-1710
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Provider Business Mailing Address
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Address Line | 5425 N PAULINA ST UNIT 2 NORTH
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City | CHICAGO
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State | IL
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Zip | 60640-1139
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Country | US
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Telephone | 773-501-3557
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Fax | 773-275-1710
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Authorized Official
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Title or Position | OWNER
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Name | PATRICIA GRAHAM
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Credential | PSYD HSPP
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Telephone | 779-275-1710
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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 | 20042049
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License Number State | IN
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