Provider Demographics
NPI:1699894766
Name:GRAHAM, JOHN ELLINGTON III (MA, MSED)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:ELLINGTON
Last Name:GRAHAM
Suffix:III
Gender:M
Credentials:MA, MSED
Other - Prefix:
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Mailing Address - Street 1:13 POINTER CT
Mailing Address - Street 2:
Mailing Address - City:LAKE ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63367-2017
Mailing Address - Country:US
Mailing Address - Phone:636-485-2900
Mailing Address - Fax:636-625-8284
Practice Address - Street 1:300 FORT ZUMWALT SQ
Practice Address - Street 2:SUITE 107
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63366-3078
Practice Address - Country:US
Practice Address - Phone:636-980-4673
Practice Address - Fax:636-625-8284
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO001763101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional