Provider Demographics
NPI:1932392537
Name:GRAHAM PSHCHOLOGICAL CONSULTING AND RESTORATION, INC
Entity Type:Organization
Organization Name:GRAHAM PSHCHOLOGICAL CONSULTING AND RESTORATION, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD HSPP
Authorized Official - Phone:779-275-1710
Mailing Address - Street 1:5425 N PAULINA ST
Mailing Address - Street 2:UNIT 2 NORTH
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-1139
Mailing Address - Country:US
Mailing Address - Phone:773-501-3557
Mailing Address - Fax:773-275-1710
Practice Address - Street 1:9111 BROADWAY
Practice Address - Street 2:SUITE Q
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-8122
Practice Address - Country:US
Practice Address - Phone:773-501-3557
Practice Address - Fax:773-275-1710
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-27
Last Update Date:2007-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20042049103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN20042049OtherINDIANA LICENSE NUMBER