Provider Demographics
NPI:1659880987
Name:GRAHAM, MICHELLE RENE (CDP)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:RENE
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:CDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 S 12TH AVE STE 4B
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-3137
Mailing Address - Country:US
Mailing Address - Phone:509-575-8457
Mailing Address - Fax:509-453-1273
Practice Address - Street 1:307 S 12TH AVE STE 4B
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-3137
Practice Address - Country:US
Practice Address - Phone:509-575-8457
Practice Address - Fax:509-453-1273
Is Sole Proprietor?:No
Enumeration Date:2017-09-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP60234989101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)