Provider Demographics
NPI:1942726344
Name:GRAHAM, COURTNEY (LCSW)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61396 S HIGHWAY 97 STE 228
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-2558
Mailing Address - Country:US
Mailing Address - Phone:973-544-8574
Mailing Address - Fax:
Practice Address - Street 1:10 SYCAMORE AVE
Practice Address - Street 2:
Practice Address - City:HO HO KUS
Practice Address - State:NJ
Practice Address - Zip Code:07423-1587
Practice Address - Country:US
Practice Address - Phone:973-544-8574
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC055912001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ44SC0559120Medicaid