Provider Demographics
NPI:1992730691
Name:GRAHAM, THEONI S (MS)
Entity type:Individual
Prefix:
First Name:THEONI
Middle Name:S
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:808 TRITON CT STE 100
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606-4520
Mailing Address - Country:US
Mailing Address - Phone:757-874-4665
Mailing Address - Fax:757-874-1286
Practice Address - Street 1:808 TRITON CT STE 100
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606-4520
Practice Address - Country:US
Practice Address - Phone:757-874-4665
Practice Address - Fax:757-874-1286
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2019-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2201000216231H00000X
VA2101 000872237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Not Answered237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA51143OtherSENTARA/OPTIMA PROVIDER
VA540972387OtherAETNA/TRICARE PROVIDER
VA386056OtherANTHEM PROVIDER NUMBER
VA0723576002OtherCIGNA PROVIDER NUMBER
VA148932100OtherDEPT OF LABOR PROVIDER
VA640004704OtherMEDICARE RAILROAD PROVIDE