Provider Demographics
NPI:1033492020
Name:GRAHAM, VICKIE ROSELEE (MSBS, MFT-US)
Entity Type:Individual
Prefix:MRS
First Name:VICKIE
Middle Name:ROSELEE
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:MSBS, MFT-US
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1719 SW 11TH ST
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73501-7305
Mailing Address - Country:US
Mailing Address - Phone:580-581-1818
Mailing Address - Fax:580-581-1819
Practice Address - Street 1:1719 SW 11TH ST
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73501-7305
Practice Address - Country:US
Practice Address - Phone:580-581-1818
Practice Address - Fax:580-581-1819
Is Sole Proprietor?:No
Enumeration Date:2011-09-26
Last Update Date:2012-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
OK106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200392130AMedicaid