Provider Demographics
NPI:1356453146
Name:GRAHAM, CARISSE CHRISTINE (PT)
Entity type:Individual
Prefix:MS
First Name:CARISSE
Middle Name:CHRISTINE
Last Name:GRAHAM
Suffix:
Gender:
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1665 HAMILTON RD STE 100
Mailing Address - Street 2:
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48864-1809
Mailing Address - Country:US
Mailing Address - Phone:517-349-1110
Mailing Address - Fax:517-349-6892
Practice Address - Street 1:1665 HAMILTON RD STE 100
Practice Address - Street 2:
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-1809
Practice Address - Country:US
Practice Address - Phone:517-349-1110
Practice Address - Fax:517-349-6892
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2025-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTL.0016875225100000X
TX1252818225100000X, 225100000X
MI5501016147225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8447187Medicaid
WA207460OtherLABOR & INDUSTRIES
WA8447187Medicaid