Provider Demographics
NPI:1053623900
Name:GRAHAM, KERILYN (DPT)
Entity type:Individual
Prefix:
First Name:KERILYN
Middle Name:
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:151 N SUNRISE AVE STE 902
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-2929
Mailing Address - Country:US
Mailing Address - Phone:602-317-3800
Mailing Address - Fax:
Practice Address - Street 1:9139 W THUNDERBIRD RD STE 225
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-4913
Practice Address - Country:US
Practice Address - Phone:602-317-3800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-08
Last Update Date:2021-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA300941225100000X
AZ8931225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ138656OtherMEDICARE PTAN