Provider Demographics
NPI:1114739968
Name:GRAHAM, COLIN (LSW)
Entity type:Individual
Prefix:
First Name:COLIN
Middle Name:
Last Name:GRAHAM
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:931 W LELAND AVE APT 402
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-6611
Mailing Address - Country:US
Mailing Address - Phone:517-214-7403
Mailing Address - Fax:
Practice Address - Street 1:500 CAPITOL MALL STE 2350
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95814-4760
Practice Address - Country:US
Practice Address - Phone:312-775-2045
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-20
Last Update Date:2025-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL39210101YA0400X
IL150.1149631041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)