Provider Demographics
NPI:1962633040
Name:GRAHAM, TERESA MARY (LICSW)
Entity Type:Individual
Prefix:MS
First Name:TERESA
Middle Name:MARY
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4837 EWING AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55410-1749
Mailing Address - Country:US
Mailing Address - Phone:612-927-9841
Mailing Address - Fax:
Practice Address - Street 1:701 DECATUR AVE N
Practice Address - Street 2:
Practice Address - City:GOLDEN VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55427-4363
Practice Address - Country:US
Practice Address - Phone:763-746-2400
Practice Address - Fax:763-746-2401
Is Sole Proprietor?:No
Enumeration Date:2009-08-06
Last Update Date:2009-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN58351041C0700X
MN2590101041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool