Provider Demographics
NPI:1629421672
Name:WILSON-GRAHAM, BRENDA (MAMFT)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:WILSON-GRAHAM
Suffix:
Gender:F
Credentials:MAMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5109 W WESTKNOLL CT
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47304-5039
Mailing Address - Country:US
Mailing Address - Phone:765-228-8970
Mailing Address - Fax:
Practice Address - Street 1:3700 W KILGORE AVE
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47304-4810
Practice Address - Country:US
Practice Address - Phone:765-289-5437
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-14
Last Update Date:2016-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN0000000A106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist