Provider Demographics
NPI:1871055764
Name:GRAHAM, ABIGAIL
Entity type:Individual
Prefix:
First Name:ABIGAIL
Middle Name:
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:408 LIBRA ST
Mailing Address - Street 2:
Mailing Address - City:ALTUS
Mailing Address - State:OK
Mailing Address - Zip Code:73521-5108
Mailing Address - Country:US
Mailing Address - Phone:850-776-0622
Mailing Address - Fax:
Practice Address - Street 1:916 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ALTUS
Practice Address - State:OK
Practice Address - Zip Code:73521-3118
Practice Address - Country:US
Practice Address - Phone:850-776-0622
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-01
Last Update Date:2025-01-16
Deactivation Date:2023-03-29
Deactivation Code:
Reactivation Date:2023-06-19
Provider Licenses
StateLicense IDTaxonomies
FL19-82557106S00000X
OK1-23-64853103K00000X, 103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician