Provider Demographics
NPI:1982343471
Name:GRAHAM, GREGORY WAYNE (LPC)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:WAYNE
Last Name:GRAHAM
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3418 TOWN AND COUNTRY DRIVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76903
Mailing Address - Country:US
Mailing Address - Phone:325-653-4673
Mailing Address - Fax:
Practice Address - Street 1:3418 TOWN & COUNTRY DRIVE
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76903
Practice Address - Country:US
Practice Address - Phone:325-653-4673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-02
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX72436101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health