Provider Demographics
NPI:1417632738
Name:GRAHAM, ALYSON JADE
Entity Type:Individual
Prefix:
First Name:ALYSON
Middle Name:JADE
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 PINE HOLLOW DR
Mailing Address - Street 2:
Mailing Address - City:VAN BUREN
Mailing Address - State:AR
Mailing Address - Zip Code:72956-7915
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6815 ISAACS ORCHARD RD STE D
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72762-6285
Practice Address - Country:US
Practice Address - Phone:479-209-0401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-15
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR4223225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant