Provider Demographics
NPI:1740378256
Name:GRAHAM, KORI DIANE (COTA/L)
Entity type:Individual
Prefix:MS
First Name:KORI
Middle Name:DIANE
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:346 S HARRISON BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:SIMPSONVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29680-6802
Mailing Address - Country:US
Mailing Address - Phone:864-313-4557
Mailing Address - Fax:
Practice Address - Street 1:1501 E GREENVILLE ST
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621-2004
Practice Address - Country:US
Practice Address - Phone:864-226-8356
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2557224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant