Provider Demographics
NPI:1730670548
Name:GRAHAM, BRUCE (LCSW)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:
Last Name:GRAHAM
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:98 YORK ST
Mailing Address - Street 2:YALE CHILD STUDY CENTER IICAPS
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:98 YORK ST
Practice Address - Street 2:YALE CHILD STUDY CENTER IICAPS
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511
Practice Address - Country:US
Practice Address - Phone:203-464-7721
Practice Address - Fax:203-785-6860
Is Sole Proprietor?:No
Enumeration Date:2018-05-29
Last Update Date:2018-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT009710104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker