Provider Demographics
NPI:1679955199
Name:GRAHAM, MICHELE A (BS PSYCHOLOGY)
Entity type:Individual
Prefix:
First Name:MICHELE
Middle Name:A
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:BS PSYCHOLOGY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 DEWEY AVE
Mailing Address - Street 2:
Mailing Address - City:POTEAU
Mailing Address - State:OK
Mailing Address - Zip Code:74953-4224
Mailing Address - Country:US
Mailing Address - Phone:918-649-0909
Mailing Address - Fax:
Practice Address - Street 1:205 DEWEY AVE
Practice Address - Street 2:
Practice Address - City:POTEAU
Practice Address - State:OK
Practice Address - Zip Code:74953-4224
Practice Address - Country:US
Practice Address - Phone:918-649-0909
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-20
Last Update Date:2015-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAA64262191103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst