Provider Demographics
NPI:1033794839
Name:GRAHAM, WILLIAM (ATC, LAT)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:
Last Name:GRAHAM
Suffix:
Gender:M
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5210 SLICKROCK DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80923-7645
Mailing Address - Country:US
Mailing Address - Phone:720-984-5402
Mailing Address - Fax:
Practice Address - Street 1:2168 FIELD HOUSE DR
Practice Address - Street 2:
Practice Address - City:USAF ACADEMY
Practice Address - State:CO
Practice Address - Zip Code:80840-9599
Practice Address - Country:US
Practice Address - Phone:719-333-0222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-12
Last Update Date:2021-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAT.00020832255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer