Provider Demographics
NPI:1790976744
Name:GRAHAM, ALICIA LYNN (LISW-S)
Entity type:Individual
Prefix:MS
First Name:ALICIA
Middle Name:LYNN
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:LISW-S
Other - Prefix:MRS
Other - First Name:ALICIA
Other - Middle Name:LYNN
Other - Last Name:BUEHRER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LISW
Mailing Address - Street 1:17420 COUNTY ROAD 17F
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:OH
Mailing Address - Zip Code:43506-9446
Mailing Address - Country:US
Mailing Address - Phone:419-310-9524
Mailing Address - Fax:
Practice Address - Street 1:22251 STATE ROUTE 2
Practice Address - Street 2:
Practice Address - City:ARCHBOLD
Practice Address - State:OH
Practice Address - Zip Code:43502-9452
Practice Address - Country:US
Practice Address - Phone:419-445-1552
Practice Address - Fax:419-445-1401
Is Sole Proprietor?:No
Enumeration Date:2007-08-06
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.0500348101YM0800X
OHI.0800184104100000X
OHI.0800184-SUPV1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0166914Medicaid
OH1790976744Medicaid