Provider Demographics
NPI:1437699121
Name:GRAHAM, CAROLYNN ELIZABETH (OTRL)
Entity Type:Individual
Prefix:MRS
First Name:CAROLYNN
Middle Name:ELIZABETH
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:MISS
Other - First Name:CAROLYNN
Other - Middle Name:ELIZABETH
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:6417 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:CASS CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48726-1115
Mailing Address - Country:US
Mailing Address - Phone:989-657-1501
Mailing Address - Fax:
Practice Address - Street 1:348 LONG RAPIDS PLZ
Practice Address - Street 2:
Practice Address - City:ALPENA
Practice Address - State:MI
Practice Address - Zip Code:49707-1374
Practice Address - Country:US
Practice Address - Phone:989-358-8086
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-01
Last Update Date:2017-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201009735225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist