Provider Demographics
NPI:1992290480
Name:GRAHAM, LEAH MOORE (MOT)
Entity type:Individual
Prefix:
First Name:LEAH
Middle Name:MOORE
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:MOT
Other - Prefix:
Other - First Name:LEAH
Other - Middle Name:VIRGINIA
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:199 N BROOKMOORE DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:MS
Mailing Address - Zip Code:39705-2024
Mailing Address - Country:US
Mailing Address - Phone:662-327-6705
Mailing Address - Fax:662-327-6760
Practice Address - Street 1:2606 N HILLS ST
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39305-2639
Practice Address - Country:US
Practice Address - Phone:601-490-9442
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-27
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSOT3536225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist