Provider Demographics
NPI:1619641016
Name:GRAHAM, AMY JOHANNA
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:JOHANNA
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:PO BOX 779
Mailing Address - Street 2:
Mailing Address - City:RUSHVILLE
Mailing Address - State:NE
Mailing Address - Zip Code:69360-0779
Mailing Address - Country:US
Mailing Address - Phone:308-327-2026
Mailing Address - Fax:
Practice Address - Street 1:309 W 3RD ST
Practice Address - Street 2:
Practice Address - City:RUSHVILLE
Practice Address - State:NE
Practice Address - Zip Code:69360-4581
Practice Address - Country:US
Practice Address - Phone:308-327-2026
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-09
Last Update Date:2021-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE12717101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health