Provider Demographics
NPI:1790976744
Name:GRAHAM, ALICIA LYNN (LISW-S)
Entity Type:Individual
Prefix:MS
First Name:ALICIA
Middle Name:LYNN
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:LISW-S
Other - Prefix:MRS
Other - First Name:ALICIA
Other - Middle Name:LYNN
Other - Last Name:BUEHRER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LISW
Mailing Address - Street 1:6605 WEST CENTRAL AVENUE
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43617-1000
Mailing Address - Country:US
Mailing Address - Phone:419-841-7701
Mailing Address - Fax:419-841-1691
Practice Address - Street 1:6605 WEST CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43617
Practice Address - Country:US
Practice Address - Phone:419-841-7701
Practice Address - Fax:419-841-1691
Is Sole Proprietor?:No
Enumeration Date:2007-08-06
Last Update Date:2018-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.08001841041C0700X, 104100000X
OHS.0500348101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1790976744Medicaid