Provider Demographics
NPI:1376384511
Name:GRAHAM, ETHAN P
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:P
Last Name:GRAHAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11520 WESTBRANCH PKWY
Mailing Address - Street 2:
Mailing Address - City:DAVIDSON
Mailing Address - State:NC
Mailing Address - Zip Code:28036-0409
Mailing Address - Country:US
Mailing Address - Phone:630-405-8948
Mailing Address - Fax:
Practice Address - Street 1:525 N TRYON ST STE 1600
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28202-0213
Practice Address - Country:US
Practice Address - Phone:855-832-6727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-03
Last Update Date:2024-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician