Provider Demographics
NPI:1427188655
Name:GRAHAM, EDWARD WILLIAM (PHD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:WILLIAM
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 1:179 MAIN ST
Mailing Address - Street 2:203
Mailing Address - City:WATERVILLE
Mailing Address - State:ME
Mailing Address - Zip Code:04901-6672
Mailing Address - Country:US
Mailing Address - Phone:207-877-9434
Mailing Address - Fax:
Practice Address - Street 1:179 MAIN ST
Practice Address - Street 2:203
Practice Address - City:WATERVILLE
Practice Address - State:ME
Practice Address - Zip Code:04901-6672
Practice Address - Country:US
Practice Address - Phone:207-877-9434
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC9321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MESTAR 005628OtherANTHEM BLUE CROSS BLUE SH