Provider Demographics
NPI:1396136354
Name:GRAHAM, NEVILLE JR (MA)
Entity type:Individual
Prefix:
First Name:NEVILLE
Middle Name:
Last Name:GRAHAM
Suffix:JR
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 LAKE AUGUST DR
Mailing Address - Street 2:
Mailing Address - City:LAKE PLACID
Mailing Address - State:FL
Mailing Address - Zip Code:33852-4021
Mailing Address - Country:US
Mailing Address - Phone:863-441-7670
Mailing Address - Fax:
Practice Address - Street 1:430 LAKE AUGUST DR
Practice Address - Street 2:
Practice Address - City:LAKE PLACID
Practice Address - State:FL
Practice Address - Zip Code:33852-4021
Practice Address - Country:US
Practice Address - Phone:863-441-7670
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-12
Last Update Date:2015-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH 10331101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health