Provider Demographics
NPI:1639202187
Name:GRAHAM, GLORIA ANN (OTR)
Entity Type:Individual
Prefix:
First Name:GLORIA
Middle Name:ANN
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13117 ASHLEY MEADOW DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28213-4852
Mailing Address - Country:US
Mailing Address - Phone:704-688-7195
Mailing Address - Fax:
Practice Address - Street 1:5700 EXECUTIVE CENTER DR
Practice Address - Street 2:SUITE 115
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28212-8858
Practice Address - Country:US
Practice Address - Phone:704-566-6040
Practice Address - Fax:704-525-9337
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5617225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics