Provider Demographics
NPI:1629106331
Name:GRAHAM, ELLEN D (PHD)
Entity Type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:D
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:TERESA
Other - Middle Name:ELLEN
Other - Last Name:GRAHAM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:2212 GLORY DR
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37043-1812
Mailing Address - Country:US
Mailing Address - Phone:931-378-7376
Mailing Address - Fax:
Practice Address - Street 1:1832 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043-6311
Practice Address - Country:US
Practice Address - Phone:931-645-3552
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2013-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2947103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist