Provider Demographics
NPI:1477725695
Name:GRAHAM, SHELLY (PHD)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8307 SHOAL CREEK BLVD
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78757-7525
Mailing Address - Country:US
Mailing Address - Phone:512-619-4966
Mailing Address - Fax:512-451-0090
Practice Address - Street 1:8307 SHOAL CREEK BLVD
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78757-7525
Practice Address - Country:US
Practice Address - Phone:512-619-4966
Practice Address - Fax:512-451-0090
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-27
Last Update Date:2008-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14192101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX14192OtherSTATE LICENSE #