1548347909 NPI number — DR. JOHN L. GRAHM PH.D.

Table of content: DR. JOHN L. GRAHM PH.D. (NPI 1548347909)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548347909 NPI number — DR. JOHN L. GRAHM PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRAHM
Provider First Name:
JOHN
Provider Middle Name:
L.
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.D.
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:
1548347909
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3362 CAJON CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SANTA ROSA VALLEY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93012-8223
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
805-529-3644
Provider Business Mailing Address Fax Number:
805-529-5421

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
360 MOBIL AVE
Provider Second Line Business Practice Location Address:
211D
Provider Business Practice Location Address City Name:
CAMARILLO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93010-6325
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-654-5671
Provider Business Practice Location Address Fax Number:
805-529-5421
Provider Enumeration Date:
11/01/2006

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: 103TC0700X , with the licence number:  PSY5296 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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