Provider Demographics
NPI:1558087296
Name:GRAHAM, EDA
Entity Type:Individual
Prefix:
First Name:EDA
Middle Name:
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 PARK LN S APT 2
Mailing Address - Street 2:
Mailing Address - City:MENANDS
Mailing Address - State:NY
Mailing Address - Zip Code:12204-1940
Mailing Address - Country:US
Mailing Address - Phone:518-935-8258
Mailing Address - Fax:
Practice Address - Street 1:2025 ROUTE 9W
Practice Address - Street 2:
Practice Address - City:RAVENA
Practice Address - State:NY
Practice Address - Zip Code:12143
Practice Address - Country:US
Practice Address - Phone:518-935-8258
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-14
Last Update Date:2022-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY117708101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY117708Medicaid