Provider Demographics
NPI:1336330208
Name:GRAHAM, GRETCHEN (DC, PT)
Entity Type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:DC, PT
Other - Prefix:
Other - First Name:GRETCHEN
Other - Middle Name:
Other - Last Name:CHERNE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DC, PT
Mailing Address - Street 1:930 PYOTT RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-8720
Mailing Address - Country:US
Mailing Address - Phone:847-854-4889
Mailing Address - Fax:847-854-4890
Practice Address - Street 1:930 PYOTT RD
Practice Address - Street 2:SUITE 102
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-8720
Practice Address - Country:US
Practice Address - Phone:847-854-4889
Practice Address - Fax:847-854-4890
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-06
Last Update Date:2011-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038.010992111N00000X
IL070018590225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No111N00000XChiropractic ProvidersChiropractor