Provider Demographics
NPI:1457160368
Name:GRAHAM, TIMOTHY GABRIEL (PSS, CRM)
Entity type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:GABRIEL
Last Name:GRAHAM
Suffix:
Gender:
Credentials:PSS, CRM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8915 SW CENTER ST
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-6307
Mailing Address - Country:US
Mailing Address - Phone:760-726-3690
Mailing Address - Fax:
Practice Address - Street 1:17440 NE FLANDERS ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97230-6632
Practice Address - Country:US
Practice Address - Phone:760-529-2076
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-06
Last Update Date:2025-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR101YM0800X175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR24-CRM-4000OtherPSS CERTIFICATION (MHACBO)