Provider Demographics
NPI:1003149766
Name:GRAHAM, RITA RAE (NCTMB)
Entity Type:Individual
Prefix:MRS
First Name:RITA
Middle Name:RAE
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:NCTMB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1244 AMERICAN WAY
Mailing Address - Street 2:
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-3936
Mailing Address - Country:US
Mailing Address - Phone:847-549-9595
Mailing Address - Fax:847-549-9596
Practice Address - Street 1:1244 AMERICAN WAY
Practice Address - Street 2:
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-3936
Practice Address - Country:US
Practice Address - Phone:847-549-9595
Practice Address - Fax:847-549-9596
Is Sole Proprietor?:No
Enumeration Date:2009-09-14
Last Update Date:2009-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227008684174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist