Provider Demographics
NPI:1356465678
Name:GRAHAM, MARJORIE KOMP (MS)
Entity Type:Individual
Prefix:MS
First Name:MARJORIE
Middle Name:KOMP
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 655
Mailing Address - Street 2:
Mailing Address - City:SKANEATELES
Mailing Address - State:NY
Mailing Address - Zip Code:13152-0655
Mailing Address - Country:US
Mailing Address - Phone:315-685-9085
Mailing Address - Fax:315-685-9085
Practice Address - Street 1:2884 SHAMROCK RD
Practice Address - Street 2:
Practice Address - City:SKANEATELES
Practice Address - State:NY
Practice Address - Zip Code:13152-8707
Practice Address - Country:US
Practice Address - Phone:315-685-9085
Practice Address - Fax:315-685-9085
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY642235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist