Provider Demographics
NPI:1093852386
Name:GRAHAM, ELISABETH ANN (MS, CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:ELISABETH
Middle Name:ANN
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16846 CHESTNUT OVERLOOK DR
Mailing Address - Street 2:
Mailing Address - City:PURCELLVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20132-2875
Mailing Address - Country:US
Mailing Address - Phone:703-864-5824
Mailing Address - Fax:703-864-5824
Practice Address - Street 1:19465 DEERFIELD AVE STE 201
Practice Address - Street 2:
Practice Address - City:LANSDOWNE
Practice Address - State:VA
Practice Address - Zip Code:20176-1703
Practice Address - Country:US
Practice Address - Phone:703-858-7620
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202003690235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA4978196Medicaid
VA4978196Medicaid