Provider Demographics
NPI:1962798314
Name:GRAHAM, LARRY E JR
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:E
Last Name:GRAHAM
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 JEWELL GRAHAM RD
Mailing Address - Street 2:
Mailing Address - City:PURVIS
Mailing Address - State:MS
Mailing Address - Zip Code:39475-3266
Mailing Address - Country:US
Mailing Address - Phone:601-550-9959
Mailing Address - Fax:
Practice Address - Street 1:820 CAMELOT DR
Practice Address - Street 2:
Practice Address - City:HARLINGEN
Practice Address - State:TX
Practice Address - Zip Code:78550-8400
Practice Address - Country:US
Practice Address - Phone:956-423-2663
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-23
Last Update Date:2019-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA12262224Z00000X
TX211236224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant