Provider Demographics
NPI:1275741530
Name:GRAHAM, THERESE R (MS OTRL)
Entity Type:Individual
Prefix:MS
First Name:THERESE
Middle Name:R
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:MS OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 VIRGINIA DR
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:AR
Mailing Address - Zip Code:72837-8999
Mailing Address - Country:US
Mailing Address - Phone:479-264-6202
Mailing Address - Fax:
Practice Address - Street 1:55 VIRGINIA DR
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:AR
Practice Address - Zip Code:72837-8999
Practice Address - Country:US
Practice Address - Phone:479-264-6202
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2007-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROTR1790225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist