Provider Demographics
NPI:1053772038
Name:GRAHAM, MYRIAM LEVESQUE (PHD)
Entity type:Individual
Prefix:DR
First Name:MYRIAM
Middle Name:LEVESQUE
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1704 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:IN
Mailing Address - Zip Code:47201-5326
Mailing Address - Country:US
Mailing Address - Phone:812-799-0074
Mailing Address - Fax:812-799-0319
Practice Address - Street 1:322 DUPONT DR
Practice Address - Street 2:
Practice Address - City:SEYMOUR
Practice Address - State:IN
Practice Address - Zip Code:47274-1723
Practice Address - Country:US
Practice Address - Phone:812-523-0386
Practice Address - Fax:812-523-8416
Is Sole Proprietor?:No
Enumeration Date:2016-03-17
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X
IN20043452A103TC0700X, 103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical