Provider Demographics
NPI:1558372334
Name:GRAHAM, KERRY E (LPC)
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:E
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 COPSE RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:CT
Mailing Address - Zip Code:06443-2323
Mailing Address - Country:US
Mailing Address - Phone:203-245-2778
Mailing Address - Fax:203-245-6098
Practice Address - Street 1:175 COPSE RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:CT
Practice Address - Zip Code:06443-2323
Practice Address - Country:US
Practice Address - Phone:203-245-2778
Practice Address - Fax:203-245-6098
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001437101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional