Provider Demographics
NPI:1508167594
Name:GRAHAM, STEPHANIE RENE (PHD)
Entity Type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:RENE
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 1:702 N BLACKHAWK AVE
Mailing Address - Street 2:SUITE 209
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53705-3357
Mailing Address - Country:US
Mailing Address - Phone:608-509-8060
Mailing Address - Fax:
Practice Address - Street 1:702 N BLACKHAWK AVE
Practice Address - Street 2:SUITE 209
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53705-3357
Practice Address - Country:US
Practice Address - Phone:608-509-8060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-08
Last Update Date:2010-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2888-057103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling