Provider Demographics
NPI:1528617164
Name:GRAHAM, MARY LIZ (MSW)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:LIZ
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:LIZ
Other - Middle Name:
Other - Last Name:GRAHAM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MSW
Mailing Address - Street 1:4124 MISSION TRACE BLVD
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32303-1702
Mailing Address - Country:US
Mailing Address - Phone:850-408-6526
Mailing Address - Fax:
Practice Address - Street 1:4124 MISSION TRACE BLVD
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32303-1702
Practice Address - Country:US
Practice Address - Phone:850-408-6526
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-06
Last Update Date:2019-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health