Provider Demographics
NPI:1053493148
Name:GRAHAM, GAYLE R
Entity Type:Individual
Prefix:MISS
First Name:GAYLE
Middle Name:R
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2034 E LINCOLN AVE
Mailing Address - Street 2:217
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92806-4101
Mailing Address - Country:US
Mailing Address - Phone:714-350-7104
Mailing Address - Fax:
Practice Address - Street 1:12440 IMPERIAL HWY
Practice Address - Street 2:116
Practice Address - City:NORWALK
Practice Address - State:CA
Practice Address - Zip Code:90650-3177
Practice Address - Country:US
Practice Address - Phone:562-651-5085
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA208591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical