Provider Demographics
NPI:1255584603
Name:GRAHAM, KELLY (LMT)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 LEE BLVD
Mailing Address - Street 2:
Mailing Address - City:LEHIGH ACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33936-4923
Mailing Address - Country:US
Mailing Address - Phone:239-369-9986
Mailing Address - Fax:239-303-9986
Practice Address - Street 1:400 LEE BLVD
Practice Address - Street 2:
Practice Address - City:LEHIGH ACRES
Practice Address - State:FL
Practice Address - Zip Code:33936-6829
Practice Address - Country:US
Practice Address - Phone:239-369-9986
Practice Address - Fax:239-368-0986
Is Sole Proprietor?:No
Enumeration Date:2008-10-29
Last Update Date:2011-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA0023317225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLC2140OtherBLUE CROSS BLUE SHIELD PROVIDER