Provider Demographics
NPI:1154632404
Name:GRAHAM, ANTHONY (BS)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:
Last Name:GRAHAM
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19329 ARDMORE ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48235-1704
Mailing Address - Country:US
Mailing Address - Phone:313-963-2266
Mailing Address - Fax:313-963-2471
Practice Address - Street 1:1700 WATERMAN ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48209-2022
Practice Address - Country:US
Practice Address - Phone:313-963-2266
Practice Address - Fax:313-963-2471
Is Sole Proprietor?:No
Enumeration Date:2010-07-01
Last Update Date:2010-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6803086243104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker