Provider Demographics
NPI:1740268515
Name:GRAHAM, VICTORIA L (ATC)
Entity type:Individual
Prefix:MS
First Name:VICTORIA
Middle Name:L
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:ATC
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Mailing Address - Street 1:25 MCKENZIE ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-4620
Mailing Address - Country:US
Mailing Address - Phone:860-398-1704
Mailing Address - Fax:
Practice Address - Street 1:WESLEYAN UNIVERSITY
Practice Address - Street 2:161 CROSS STREET
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06459-0001
Practice Address - Country:US
Practice Address - Phone:860-685-3980
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-03
Last Update Date:2011-04-19
Deactivation Date:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
000090279OtherBOC NUMBER
CT#000052OtherSTATE LICENSE