Provider Demographics
NPI:1700528791
Name:GRAHAM, MARY MARIE (LPC, CRC, CYT-200)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:MARIE
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:LPC, CRC, CYT-200
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:MARIE
Other - Last Name:WATKINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRC, LPC
Mailing Address - Street 1:20141 WESTWIND CT
Mailing Address - Street 2:
Mailing Address - City:YORBA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92886-6723
Mailing Address - Country:US
Mailing Address - Phone:312-342-4351
Mailing Address - Fax:
Practice Address - Street 1:20141 WESTWIND CT
Practice Address - Street 2:
Practice Address - City:YORBA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92886-6723
Practice Address - Country:US
Practice Address - Phone:312-342-4351
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-10
Last Update Date:2022-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.013084101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional