Provider Demographics
NPI:1225863988
Name:GRAHAM, REBECCA A (MAT)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:A
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:MAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1090 ALA NAPUNANI ST APT 305
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96818-1791
Mailing Address - Country:US
Mailing Address - Phone:423-220-6194
Mailing Address - Fax:
Practice Address - Street 1:4510 SALT LAKE BLVD STE B6
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96818-3171
Practice Address - Country:US
Practice Address - Phone:808-321-7135
Practice Address - Fax:808-200-3607
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-03
Last Update Date:2024-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMAT-17879225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty