Provider Demographics
NPI:1750411765
Name:GRAHAM, BERNADINE M (MA)
Entity type:Individual
Prefix:MS
First Name:BERNADINE
Middle Name:M
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:MA
Other - Prefix:MS
Other - First Name:DEANE
Other - Middle Name:
Other - Last Name:GRA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA
Mailing Address - Street 1:825 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:RIVER FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60305-1327
Mailing Address - Country:US
Mailing Address - Phone:708-771-8442
Mailing Address - Fax:708-771-8442
Practice Address - Street 1:233 E ERIE ST
Practice Address - Street 2:601
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2926
Practice Address - Country:US
Practice Address - Phone:312-943-7166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01628006OtherBCBS