Provider Demographics
NPI:1104948397
Name:GRAHAM, MARCIA
Entity type:Individual
Prefix:
First Name:MARCIA
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 1:589 S KENNETH PL
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85226-4674
Mailing Address - Country:US
Mailing Address - Phone:480-216-9499
Mailing Address - Fax:602-678-5803
Practice Address - Street 1:1235 E HARMONT DR
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85020-3864
Practice Address - Country:US
Practice Address - Phone:602-331-1470
Practice Address - Fax:602-678-5803
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0454225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist