Provider Demographics
NPI:1477866812
Name:GRAHAM, ETHAN (PHD)
Entity Type:Individual
Prefix:DR
First Name:ETHAN
Middle Name:
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 1:320 7TH AVE # 330
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11215-4194
Mailing Address - Country:US
Mailing Address - Phone:718-702-2437
Mailing Address - Fax:
Practice Address - Street 1:330 W 58TH ST STE 405
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-1820
Practice Address - Country:US
Practice Address - Phone:718-702-2437
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-14
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018415103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical