Provider Demographics
NPI:1154798411
Name:GRAHAM, GILLIAN (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:GILLIAN
Middle Name:
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:417 LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01104-3736
Mailing Address - Country:US
Mailing Address - Phone:413-747-0705
Mailing Address - Fax:
Practice Address - Street 1:417 LIBERTY ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01104-3736
Practice Address - Country:US
Practice Address - Phone:413-747-0705
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-21
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY401915363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health