Provider Demographics
NPI:1982031118
Name:GRAHAM, LEESA
Entity Type:Individual
Prefix:
First Name:LEESA
Middle Name:
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 E 15TH ST
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-5412
Mailing Address - Country:US
Mailing Address - Phone:850-522-4485
Mailing Address - Fax:850-522-4484
Practice Address - Street 1:16869 NE PEAR ST
Practice Address - Street 2:
Practice Address - City:BLOUNTSTOWN
Practice Address - State:FL
Practice Address - Zip Code:32424-1774
Practice Address - Country:US
Practice Address - Phone:850-522-4485
Practice Address - Fax:850-522-4484
Is Sole Proprietor?:No
Enumeration Date:2013-10-02
Last Update Date:2013-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator