Provider Demographics
NPI:1689066771
Name:GRAHAM-MINEART, THERESA
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:GRAHAM-MINEART
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:
Other - Last Name:GRAHAM-MINEART
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMHC
Mailing Address - Street 1:520 11TH ST NW
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52405-3811
Mailing Address - Country:US
Mailing Address - Phone:319-398-3562
Mailing Address - Fax:319-398-3501
Practice Address - Street 1:740 N 15TH AVE
Practice Address - Street 2:STE A
Practice Address - City:HIAWATHA
Practice Address - State:IA
Practice Address - Zip Code:52233-2384
Practice Address - Country:US
Practice Address - Phone:319-398-3562
Practice Address - Fax:319-398-3501
Is Sole Proprietor?:No
Enumeration Date:2015-02-26
Last Update Date:2015-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001725101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0074575Medicaid