Provider Demographics
NPI:1023152667
Name:GRAHAM, JOHN ALEXANDER ERIC (PSYCHOLOGIST)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:ALEXANDER ERIC
Last Name:GRAHAM
Suffix:
Gender:M
Credentials:PSYCHOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:485 HWY 71 N
Mailing Address - Street 2:
Mailing Address - City:HINES
Mailing Address - State:MN
Mailing Address - Zip Code:56647-5798
Mailing Address - Country:US
Mailing Address - Phone:218-586-4057
Mailing Address - Fax:
Practice Address - Street 1:403 4TH ST NW STE 110
Practice Address - Street 2:
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-3155
Practice Address - Country:US
Practice Address - Phone:218-586-4057
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN301343101YA0400X
MNLP2659103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist