Provider Demographics
NPI:1306359195
Name:GRAHAM, GARRY (MA, MPH, LMHC, CASAC)
Entity Type:Individual
Prefix:
First Name:GARRY
Middle Name:
Last Name:GRAHAM
Suffix:
Gender:M
Credentials:MA, MPH, LMHC, CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3407 GRACE AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10469-2611
Mailing Address - Country:US
Mailing Address - Phone:718-514-0959
Mailing Address - Fax:
Practice Address - Street 1:3407 GRACE AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10469-2612
Practice Address - Country:US
Practice Address - Phone:718-514-0959
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-15
Last Update Date:2017-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004188101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health