Provider Demographics
NPI:1093351645
Name:GRAHAM, LORI
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:
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 1:15531 UPPER CAROLINA
Mailing Address - Street 2:
Mailing Address - City:ST JOHN
Mailing Address - State:VI
Mailing Address - Zip Code:00830-9518
Mailing Address - Country:US
Mailing Address - Phone:317-691-4608
Mailing Address - Fax:
Practice Address - Street 1:6115 ESTATE SMITH BAY
Practice Address - Street 2:
Practice Address - City:ST THOMAS
Practice Address - State:VI
Practice Address - Zip Code:00802-1324
Practice Address - Country:US
Practice Address - Phone:340-714-2348
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-19
Last Update Date:2019-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant