Provider Demographics
NPI:1295039774
Name:GRAHAM, RAYMOND B (LCSW)
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:B
Last Name:GRAHAM
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 BAYOU ST
Mailing Address - Street 2:
Mailing Address - City:VINCENNES
Mailing Address - State:IN
Mailing Address - Zip Code:47591-1034
Mailing Address - Country:US
Mailing Address - Phone:812-886-6800
Mailing Address - Fax:812-886-6809
Practice Address - Street 1:121 BUNTIN ST
Practice Address - Street 2:
Practice Address - City:VINCENNES
Practice Address - State:IN
Practice Address - Zip Code:47591-1320
Practice Address - Country:US
Practice Address - Phone:812-885-2700
Practice Address - Fax:812-885-2716
Is Sole Proprietor?:No
Enumeration Date:2010-12-27
Last Update Date:2011-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34005952A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100270140Medicaid
IN444530OtherMEDICARE, PENDING