Provider Demographics
NPI:1871545798
Name:GRAHAM, SHARROD DAVID (ATC,CSCS)
Entity type:Individual
Prefix:MR
First Name:SHARROD
Middle Name:DAVID
Last Name:GRAHAM
Suffix:
Gender:M
Credentials:ATC,CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 LESTER RD
Mailing Address - Street 2:B
Mailing Address - City:PARK FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60466-2012
Mailing Address - Country:US
Mailing Address - Phone:773-419-8822
Mailing Address - Fax:
Practice Address - Street 1:110 LESTER RD
Practice Address - Street 2:B
Practice Address - City:PARK FOREST
Practice Address - State:IL
Practice Address - Zip Code:60466-2012
Practice Address - Country:US
Practice Address - Phone:773-419-8822
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer