Provider Demographics
NPI:1134769441
Name:KNOWLTON, GRAHAM GARDNER (PHD)
Entity type:Individual
Prefix:DR
First Name:GRAHAM
Middle Name:GARDNER
Last Name:KNOWLTON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5000 W NATIONAL AVE
Mailing Address - Street 2:ACUTE MENTAL HEALTH DIVISION
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53295
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:MILWAUKEE VAMC 5000 W NATIONAL AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53295-0001
Practice Address - Country:US
Practice Address - Phone:414-384-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-14
Last Update Date:2020-03-12
Deactivation Date:2020-01-25
Deactivation Code:
Reactivation Date:2020-03-12
Provider Licenses
StateLicense IDTaxonomies
WI375257103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling