Provider Demographics
NPI:1851626881
Name:GRAHAM, STACI JANAE
Entity Type:Individual
Prefix:
First Name:STACI
Middle Name:JANAE
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1215 W WEST COVINA PKWY
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91790-2946
Mailing Address - Country:US
Mailing Address - Phone:626-974-0770
Mailing Address - Fax:
Practice Address - Street 1:1215 W WEST COVINA PKWY
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790-2946
Practice Address - Country:US
Practice Address - Phone:626-974-0770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-08
Last Update Date:2016-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist