Provider Demographics
NPI:1205573904
Name:GRAHAM, KATIE AMBER (MS)
Entity type:Individual
Prefix:MRS
First Name:KATIE
Middle Name:AMBER
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3000 OLIVER ST
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59718-6067
Mailing Address - Country:US
Mailing Address - Phone:406-920-1499
Mailing Address - Fax:
Practice Address - Street 1:1174 STONERIDGE DR
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59718-9850
Practice Address - Country:US
Practice Address - Phone:406-551-6295
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-16
Last Update Date:2022-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT56655101YM0800X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty