Provider Demographics
NPI:1245785237
Name:GRAHAM, FERNANDEZ A
Entity Type:Individual
Prefix:MR
First Name:FERNANDEZ
Middle Name:A
Last Name:GRAHAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3610 LAKESIDE DR
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71119-6516
Mailing Address - Country:US
Mailing Address - Phone:318-560-3002
Mailing Address - Fax:
Practice Address - Street 1:3610 LAKESIDE DR
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71119-6516
Practice Address - Country:US
Practice Address - Phone:318-560-3002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-18
Last Update Date:2016-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor