Provider Demographics
NPI:1073856373
Name:GRAHAM, LORI (MA)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 EL PUEBLO RANCH WAY
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81006-2103
Mailing Address - Country:US
Mailing Address - Phone:719-404-1132
Mailing Address - Fax:719-544-7705
Practice Address - Street 1:1 EL PUEBLO RANCH WAY
Practice Address - Street 2:ERICA PRUETT/WATTS, FINANCE OFFICE
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81006-2103
Practice Address - Country:US
Practice Address - Phone:719-404-1132
Practice Address - Fax:719-544-7705
Is Sole Proprietor?:No
Enumeration Date:2013-04-04
Last Update Date:2013-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO6047101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO00000000Medicaid