Provider Demographics
NPI:1952099376
Name:GRAHAM, TISHA (CPM, ICBD, ICCE, CLC)
Entity Type:Individual
Prefix:MS
First Name:TISHA
Middle Name:
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:CPM, ICBD, ICCE, CLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 WASHINGTON AVENUE
Mailing Address - Street 2:P.O. BOX 41
Mailing Address - City:ROUND LAKE
Mailing Address - State:NY
Mailing Address - Zip Code:12151
Mailing Address - Country:US
Mailing Address - Phone:518-366-2159
Mailing Address - Fax:
Practice Address - Street 1:40 WASHINGTON AVENUE
Practice Address - Street 2:
Practice Address - City:ROUND LAKE
Practice Address - State:NY
Practice Address - Zip Code:12151
Practice Address - Country:US
Practice Address - Phone:518-366-2159
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-25
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174N00000X, 374J00000X
VT107.0085724176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
No174N00000XOther Service ProvidersLactation Consultant, Non-RN
No374J00000XNursing Service Related ProvidersDoula