Provider Demographics
NPI:1972847341
Name:GRAHAM, HEATHER LYNN (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:LYNN
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 4TH ST N
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58102-4514
Mailing Address - Country:US
Mailing Address - Phone:701-446-1000
Mailing Address - Fax:701-446-1200
Practice Address - Street 1:1729 16TH ST S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-4829
Practice Address - Country:US
Practice Address - Phone:701-446-4800
Practice Address - Fax:701-446-4899
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-25
Last Update Date:2012-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND000417663235Z00000X
ND1198235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist