Provider Demographics
NPI:1871945071
Name:GRAHAM, RONALD
Entity type:Individual
Prefix:
First Name:RONALD
Middle Name:
Last Name:GRAHAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:358 E BIRCH AVE
Mailing Address - Street 2:#101
Mailing Address - City:COLVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:99114-2762
Mailing Address - Country:US
Mailing Address - Phone:509-684-3200
Mailing Address - Fax:
Practice Address - Street 1:358 E BIRCH AVE
Practice Address - Street 2:#101
Practice Address - City:COLVILLE
Practice Address - State:WA
Practice Address - Zip Code:99114-2762
Practice Address - Country:US
Practice Address - Phone:509-684-3200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-12
Last Update Date:2016-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WASC60672016101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health