Provider Demographics
NPI:1891421806
Name:GRAHAM, PAUL/VIV
Entity type:Individual
Prefix:
First Name:PAUL/VIV
Middle Name:
Last Name:GRAHAM
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:PAUL
Other - Middle Name:
Other - Last Name:GRAHAM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:12836 LOMAS BLVD NE STE C
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87112-6200
Mailing Address - Country:US
Mailing Address - Phone:505-710-6530
Mailing Address - Fax:
Practice Address - Street 1:12836 LOMAS BLVD NE STE C
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87112-6200
Practice Address - Country:US
Practice Address - Phone:505-710-6530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-01
Last Update Date:2024-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
NMSWB-2024-0565104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician