1174800791 NPI number — ETHAN A GRAHAM PHD PSYCHOLOGIST PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174800791 NPI number — ETHAN A GRAHAM PHD PSYCHOLOGIST PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ETHAN A GRAHAM PHD PSYCHOLOGIST PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1174800791
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/10/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
330 WEST 58TH STREET
Provider Second Line Business Mailing Address:
SUITE 405
Provider Business Mailing Address City Name:
NEW YORK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10019-1820
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-702-2437
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
330 WEST 58TH STREET
Provider Second Line Business Practice Location Address:
SUITE 405
Provider Business Practice Location Address City Name:
NEW YORK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10019-1820
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-702-2437
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/10/2011

Additional Information

Authorized Official

Authorized Official Last Name:
GRAHAM
Authorized Official First Name:
ETHAN
Authorized Official Middle Name:
A
Authorized Official Title or Position:
PSYCHOLOGIST
Authorized Official Telephone Number:
718-702-2437

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  018415 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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