Provider Demographics
NPI:1356706287
Name:GRAHAM, CARLY
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 AMBER BEACH ROAD
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:NY
Mailing Address - Zip Code:13310
Mailing Address - Country:US
Mailing Address - Phone:315-729-9056
Mailing Address - Fax:
Practice Address - Street 1:212 AMBER BEACH ROAD
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:NY
Practice Address - Zip Code:13310
Practice Address - Country:US
Practice Address - Phone:315-729-9056
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-18
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01649600225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist