Provider Demographics
NPI:1881641603
Name:GRAHAM, RITA KAIS (PT)
Entity Type:Individual
Prefix:
First Name:RITA
Middle Name:KAIS
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61 COMMERCE AVE SW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4124
Mailing Address - Country:US
Mailing Address - Phone:616-940-0660
Mailing Address - Fax:616-940-1965
Practice Address - Street 1:2060 E PARIS AVE SE
Practice Address - Street 2:SUITE 200
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-6501
Practice Address - Country:US
Practice Address - Phone:616-285-1377
Practice Address - Fax:616-285-1154
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2012-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501011787225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI650D115970OtherBCBSM
MIP03810005Medicare PIN