Provider Demographics
NPI:1851672042
Name:GRAHAM, KASSIDY (LPC)
Entity Type:Individual
Prefix:
First Name:KASSIDY
Middle Name:
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 DOWNEY ST
Mailing Address - Street 2:
Mailing Address - City:LARAMIE
Mailing Address - State:WY
Mailing Address - Zip Code:82072-1845
Mailing Address - Country:US
Mailing Address - Phone:307-745-8997
Mailing Address - Fax:
Practice Address - Street 1:4989 N 3RD ST
Practice Address - Street 2:
Practice Address - City:LARAMIE
Practice Address - State:WY
Practice Address - Zip Code:82072-9548
Practice Address - Country:US
Practice Address - Phone:307-745-8997
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-01
Last Update Date:2012-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY532101Y00000X
WYLPC - 1267101YP2500X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYLPC - 1267OtherSTATE LICENSE
WY532OtherSTATE LICENSE