1457160368 NPI number — MR. TIMOTHY GABRIEL GRAHAM PSS, CRM

Table of content: HARRIET KATZ PT (NPI 1336346253)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457160368 NPI number — MR. TIMOTHY GABRIEL GRAHAM PSS, CRM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRAHAM
Provider First Name:
TIMOTHY
Provider Middle Name:
GABRIEL
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PSS, CRM
Provider Gender Code:
M

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:
1457160368
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/21/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8915 SW CENTER ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TIGARD
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97223-6307
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-726-3690
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17440 NE FLANDERS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97230-6632
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-529-2076
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/06/2025

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: 175T00000X , with the licence number:  101YM0800X , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 24-CRM-4000 . This is a "PSS CERTIFICATION (MHACBO)" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".