Provider Demographics
NPI:1689001224
Name:GRAHAM, COLIN BRAD (OTR)
Entity Type:Individual
Prefix:MR
First Name:COLIN
Middle Name:BRAD
Last Name:GRAHAM
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1903 CRESTHAVEN DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78704-2754
Mailing Address - Country:US
Mailing Address - Phone:512-318-8342
Mailing Address - Fax:
Practice Address - Street 1:1903 CRESTHAVEN DR
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78704-2754
Practice Address - Country:US
Practice Address - Phone:512-318-8342
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-27
Last Update Date:2013-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX110887225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist