Provider Demographics
NPI:1164264248
Name:GRAHAM, CHRISTOPHER MICHAEL (MA 61558596)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:MICHAEL
Last Name:GRAHAM
Suffix:
Gender:M
Credentials:MA 61558596
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6509 20TH ST E
Mailing Address - Street 2:
Mailing Address - City:FIFE
Mailing Address - State:WA
Mailing Address - Zip Code:98424-3505
Mailing Address - Country:US
Mailing Address - Phone:253-363-7631
Mailing Address - Fax:
Practice Address - Street 1:6509 20TH ST E
Practice Address - Street 2:
Practice Address - City:FIFE
Practice Address - State:WA
Practice Address - Zip Code:98424-3505
Practice Address - Country:US
Practice Address - Phone:253-363-7631
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-10
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61558596225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist