Provider Demographics
NPI:1336474709
Name:GRAHAM, OTHADELL NA (LISW)
Entity Type:Individual
Prefix:MS
First Name:OTHADELL
Middle Name:NA
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24300 CHAGRIN BLVD
Mailing Address - Street 2:303
Mailing Address - City:BEACHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44122-5639
Mailing Address - Country:US
Mailing Address - Phone:216-556-0696
Mailing Address - Fax:216-932-3091
Practice Address - Street 1:24300 CHAGRIN BLVD
Practice Address - Street 2:303
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-5639
Practice Address - Country:US
Practice Address - Phone:216-556-0696
Practice Address - Fax:216-932-3091
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-02
Last Update Date:2009-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0002629101YM0800X
101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional