Provider Demographics
NPI:1750855334
Name:GRAHAM, ELIZABETH (RBT)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5694 MISSION CENTER RD
Mailing Address - Street 2:SUITE 602 PMB 341
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-4324
Mailing Address - Country:US
Mailing Address - Phone:619-272-0090
Mailing Address - Fax:619-220-0215
Practice Address - Street 1:7860 MISSION CENTER CT STE 100
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-1330
Practice Address - Country:US
Practice Address - Phone:619-272-0090
Practice Address - Fax:619-220-0215
Is Sole Proprietor?:No
Enumeration Date:2019-01-16
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-18-58222106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician