Provider Demographics
NPI:1013552694
Name:GRAHAM, STACIE (BCBA)
Entity type:Individual
Prefix:
First Name:STACIE
Middle Name:
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 CASTAWAY CT NE
Mailing Address - Street 2:
Mailing Address - City:LUDOWICI
Mailing Address - State:GA
Mailing Address - Zip Code:31316-6294
Mailing Address - Country:US
Mailing Address - Phone:719-460-1129
Mailing Address - Fax:
Practice Address - Street 1:117 CASTAWAY CT NE
Practice Address - Street 2:
Practice Address - City:LUDOWICI
Practice Address - State:GA
Practice Address - Zip Code:31316-6294
Practice Address - Country:US
Practice Address - Phone:719-460-1129
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-07
Last Update Date:2025-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1-24-78469103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst