Provider Demographics
NPI:1154547750
Name:GRAHAM, NITA SUE (LSW)
Entity type:Individual
Prefix:MRS
First Name:NITA
Middle Name:SUE
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 TIMBER LAKES EST
Mailing Address - Street 2:
Mailing Address - City:HEBER CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84032-9651
Mailing Address - Country:US
Mailing Address - Phone:435-654-3003
Mailing Address - Fax:435-654-0309
Practice Address - Street 1:55 S 500 E
Practice Address - Street 2:
Practice Address - City:HEBER CITY
Practice Address - State:UT
Practice Address - Zip Code:84032-1918
Practice Address - Country:US
Practice Address - Phone:435-654-3003
Practice Address - Fax:435-654-3090
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6332320-3503104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker