Provider Demographics
NPI:1427155175
Name:GRAHAM, ELLEN ANNE (LCSW)
Entity type:Individual
Prefix:MS
First Name:ELLEN
Middle Name:ANNE
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:ELLEN
Other - Middle Name:ANNE
Other - Last Name:GRAHAM-POTTORFF
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:1346 N MULBERRY AVE
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-2739
Mailing Address - Country:US
Mailing Address - Phone:909-996-6217
Mailing Address - Fax:
Practice Address - Street 1:1346 N MULBERRY AVE
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-2739
Practice Address - Country:US
Practice Address - Phone:909-996-6217
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-17
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS13618101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health