Provider Demographics
NPI:1083162291
Name:GRAHAM, KAITLIN (SLP)
Entity Type:Individual
Prefix:MISS
First Name:KAITLIN
Middle Name:
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5415 N BLOOMFIELD RD
Mailing Address - Street 2:
Mailing Address - City:CANANDAIGUA
Mailing Address - State:NY
Mailing Address - Zip Code:14424-7964
Mailing Address - Country:US
Mailing Address - Phone:585-394-9510
Mailing Address - Fax:585-394-5326
Practice Address - Street 1:5415 N BLOOMFIELD RD
Practice Address - Street 2:
Practice Address - City:CANANDAIGUA
Practice Address - State:NY
Practice Address - Zip Code:14424-7964
Practice Address - Country:US
Practice Address - Phone:585-394-9510
Practice Address - Fax:585-394-5326
Is Sole Proprietor?:No
Enumeration Date:2016-09-16
Last Update Date:2016-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025933235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY336527Medicare UPIN
NY00355344Medicaid