Provider Demographics
NPI:1932526100
Name:GRAHAM, KATIE (MSC)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:MSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4339 WINSTON AVE
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:41015-1739
Mailing Address - Country:US
Mailing Address - Phone:859-835-2573
Mailing Address - Fax:859-727-6327
Practice Address - Street 1:4339 WINSTON AVE
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:KY
Practice Address - Zip Code:41015-1739
Practice Address - Country:US
Practice Address - Phone:859-835-2573
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-25
Last Update Date:2018-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2013-041101YM0800X
KY130656101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY130656Medicaid
KY2013-041Medicaid