Provider Demographics
NPI:1255852885
Name:GRAHAM, LORI KATHERINE (DPT)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:KATHERINE
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:LORI
Other - Middle Name:KATHERINE
Other - Last Name:VAUGHN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2222
Mailing Address - Fax:
Practice Address - Street 1:1520 E GREENVILLE ST STE G
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621-2056
Practice Address - Country:US
Practice Address - Phone:864-261-3099
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-05
Last Update Date:2017-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8599225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPENDINGMedicaid