1497012074 NPI number — DEBORAH V GRAHAM LCPO

Table of content: DEBORAH V GRAHAM LCPO (NPI 1497012074)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497012074 NPI number — DEBORAH V GRAHAM LCPO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRAHAM
Provider First Name:
DEBORAH
Provider Middle Name:
V
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCPO
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1497012074
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/19/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 99283
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT WORTH
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76199-0283
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-877-0294
Provider Business Mailing Address Fax Number:
817-877-0304

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1719 8TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT WORTH
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76110-1349
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
682-885-6294
Provider Business Practice Location Address Fax Number:
682-885-1135
Provider Enumeration Date:
04/19/2012

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 222Z00000X , with the licence number:  52 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 224P00000X , with the licence number: 52 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)