Provider Demographics
NPI:1710528617
Name:GRAHAM, LARRY J JR
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:J
Last Name:GRAHAM
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1225 E BIG BEAVER RD
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-1905
Mailing Address - Country:US
Mailing Address - Phone:248-524-8801
Mailing Address - Fax:248-524-8850
Practice Address - Street 1:1284 MAURER AVE
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48342-1960
Practice Address - Country:US
Practice Address - Phone:248-252-1427
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-01
Last Update Date:2019-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness