Provider Demographics
NPI:1548347909
Name:GRAHM, JOHN L (PHD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:L
Last Name:GRAHM
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3362 CAJON CIR
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93012-8223
Mailing Address - Country:US
Mailing Address - Phone:805-529-3644
Mailing Address - Fax:805-529-5421
Practice Address - Street 1:360 MOBIL AVE
Practice Address - Street 2:211D
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93010-6325
Practice Address - Country:US
Practice Address - Phone:805-654-5671
Practice Address - Fax:805-529-5421
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY5296103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAR26203Medicare UPIN
CACP5296Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER