Provider Demographics
NPI:1235812702
Name:GRAHAM, KATHY L
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:L
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KATHY
Other - Middle Name:LYNNE
Other - Last Name:FAHEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1411 W 190TH ST STE 110
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90248-4370
Mailing Address - Country:US
Mailing Address - Phone:310-719-3908
Mailing Address - Fax:
Practice Address - Street 1:1411 W 190TH ST STE 110
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90248-4370
Practice Address - Country:US
Practice Address - Phone:310-719-3908
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-10
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician