Provider Demographics
NPI:1447735907
Name:GRAHAM, KEITH ALLEN (ATC/L)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:ALLEN
Last Name:GRAHAM
Suffix:
Gender:M
Credentials:ATC/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 MEDICAL PARK DRIVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MALTA
Mailing Address - State:NY
Mailing Address - Zip Code:12020
Mailing Address - Country:US
Mailing Address - Phone:518-363-8710
Mailing Address - Fax:
Practice Address - Street 1:8 MEDICAL PARK DRIVE
Practice Address - Street 2:SUITE 100
Practice Address - City:MALTA
Practice Address - State:NY
Practice Address - Zip Code:12020
Practice Address - Country:US
Practice Address - Phone:518-363-8710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-01
Last Update Date:2018-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT104.00001022255A2300X
NY003760-12255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer