Provider Demographics
NPI:1619566056
Name:GRAHAM, TREVOR (MBA, LMT, C-MMP)
Entity Type:Individual
Prefix:MR
First Name:TREVOR
Middle Name:
Last Name:GRAHAM
Suffix:
Gender:M
Credentials:MBA, LMT, C-MMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7004 MASON ST
Mailing Address - Street 2:
Mailing Address - City:DISTRICT HEIGHTS
Mailing Address - State:MD
Mailing Address - Zip Code:20747-2336
Mailing Address - Country:US
Mailing Address - Phone:301-651-5931
Mailing Address - Fax:
Practice Address - Street 1:9300 WOODMORE CENTER DR STE 212
Practice Address - Street 2:
Practice Address - City:LANHAM
Practice Address - State:MD
Practice Address - Zip Code:20706-1664
Practice Address - Country:US
Practice Address - Phone:301-364-3400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-11
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDM05290225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist