Provider Demographics
NPI:1386361889
Name:GRAHAM, ADALYN SNOW
Entity type:Individual
Prefix:
First Name:ADALYN
Middle Name:SNOW
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 1:1755 LEON RD APT 2321
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32246-8674
Mailing Address - Country:US
Mailing Address - Phone:727-290-5120
Mailing Address - Fax:
Practice Address - Street 1:8777 SAN JOSE BLVD STE 801
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32217-4291
Practice Address - Country:US
Practice Address - Phone:904-374-6403
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-25
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLBACB787486103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst