Provider Demographics
NPI:1790533578
Name:GRAHAM, CHANEL KENYATA
Entity type:Individual
Prefix:
First Name:CHANEL
Middle Name:KENYATA
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7125 ORCHARD LAKE RD STE 110
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-3616
Mailing Address - Country:US
Mailing Address - Phone:248-702-6132
Mailing Address - Fax:248-702-6133
Practice Address - Street 1:7125 ORCHARD LAKE RD STE 110
Practice Address - Street 2:
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-3616
Practice Address - Country:US
Practice Address - Phone:248-702-6132
Practice Address - Fax:248-702-6133
Is Sole Proprietor?:No
Enumeration Date:2024-05-08
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704352459363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health