Provider Demographics
NPI:1326292244
Name:GRAHAM, PHYLLIS (TEACHER)
Entity Type:Individual
Prefix:MRS
First Name:PHYLLIS
Middle Name:
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:TEACHER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 DEKRUIF PLACE
Mailing Address - Street 2:22J
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10475-2419
Mailing Address - Country:US
Mailing Address - Phone:646-408-6497
Mailing Address - Fax:718-671-7976
Practice Address - Street 1:100 DEKRUIF PLACE
Practice Address - Street 2:#22J
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10475-2419
Practice Address - Country:US
Practice Address - Phone:646-408-6497
Practice Address - Fax:718-671-7976
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-05
Last Update Date:2008-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY20-4097009252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency