Provider Demographics
NPI:1285845834
Name:GRAHAM, B ETSY B
Entity type:Individual
Prefix:MS
First Name:B ETSY
Middle Name:B
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 1:9624 E SUTTON DR
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85260-4407
Mailing Address - Country:US
Mailing Address - Phone:480-332-1379
Mailing Address - Fax:480-767-7953
Practice Address - Street 1:9624 E SUTTON DR
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85260-4407
Practice Address - Country:US
Practice Address - Phone:480-332-1379
Practice Address - Fax:480-767-7953
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZT4220235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZT 4220OtherSPEECH THERAPY LICENSE NU