Provider Demographics
NPI:1689801813
Name:GRAHAM, MICHAEL PATRICK JOHN (MA , LPCC)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:PATRICK JOHN
Last Name:GRAHAM
Suffix:
Gender:M
Credentials:MA , LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3705 MARQUETTE AVE NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87108-1031
Mailing Address - Country:US
Mailing Address - Phone:505-254-3896
Mailing Address - Fax:
Practice Address - Street 1:3705 MARQUETTE AVE NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-1031
Practice Address - Country:US
Practice Address - Phone:505-254-3896
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-15
Last Update Date:2009-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2235101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional