Provider Demographics
NPI:1053724187
Name:GRAHAM, ASHLEY
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:239 SW ARMAND PL
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32025-2608
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:239 SW ARMAND PL
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-2608
Practice Address - Country:US
Practice Address - Phone:352-301-6163
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-05
Last Update Date:2014-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness