Provider Demographics
NPI:1629454657
Name:GRAHAM, CAROL
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:
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 1:12450 NE 91ST COURT
Mailing Address - Street 2:
Mailing Address - City:ARCHER
Mailing Address - State:FL
Mailing Address - Zip Code:32618
Mailing Address - Country:US
Mailing Address - Phone:954-851-4941
Mailing Address - Fax:
Practice Address - Street 1:12450 NE 91ST CT
Practice Address - Street 2:
Practice Address - City:ARCHER
Practice Address - State:FL
Practice Address - Zip Code:32618-6119
Practice Address - Country:US
Practice Address - Phone:954-851-4941
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-31
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator