Provider Demographics
NPI:1972959427
Name:GRAHAM, ERYN LEE (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:ERYN
Middle Name:LEE
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 1:407 16TH AVE S
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:64034-9782
Mailing Address - Country:US
Mailing Address - Phone:816-560-5641
Mailing Address - Fax:
Practice Address - Street 1:407 16TH AVE S
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:MO
Practice Address - Zip Code:64034-9782
Practice Address - Country:US
Practice Address - Phone:816-560-5641
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-13
Last Update Date:2021-08-11
Deactivation Date:2021-07-12
Deactivation Code:
Reactivation Date:2021-08-11
Provider Licenses
StateLicense IDTaxonomies
MO2015028861235Z00000X
COSLP.0002368235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist