Provider Demographics
NPI:1720758998
Name:GRAHAM, ELIOT
Entity Type:Individual
Prefix:
First Name:ELIOT
Middle Name:
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 1:2230 N RESERVE ST STE 300
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59808-1364
Mailing Address - Country:US
Mailing Address - Phone:406-544-5694
Mailing Address - Fax:
Practice Address - Street 1:32 CAMPUS DR
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801
Practice Address - Country:US
Practice Address - Phone:406-544-5694
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-17
Last Update Date:2023-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT63588101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health