Provider Demographics
NPI:1407808082
Name:GRAHAM, GEORGE WAYNE (PHD)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:WAYNE
Last Name:GRAHAM
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 HIGHWAY 365
Mailing Address - Street 2:SUITE 110
Mailing Address - City:NEDERLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77627-6256
Mailing Address - Country:US
Mailing Address - Phone:409-729-0400
Mailing Address - Fax:866-573-8008
Practice Address - Street 1:2300 HIGHWAY 365
Practice Address - Street 2:SUITE 110
Practice Address - City:NEDERLAND
Practice Address - State:TX
Practice Address - Zip Code:77627-6256
Practice Address - Country:US
Practice Address - Phone:409-729-0400
Practice Address - Fax:866-573-8008
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX21232103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX142037401Medicaid
TX83081PMedicare PIN
TX8F3386Medicare PIN