Provider Demographics
NPI:1619641016
Name:GRAHAM, AMY JOHANNA
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:JOHANNA
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:910 BORDEAUX STREET
Mailing Address - Street 2:
Mailing Address - City:CHADRON
Mailing Address - State:NE
Mailing Address - Zip Code:69337-2617
Mailing Address - Country:US
Mailing Address - Phone:308-856-9707
Mailing Address - Fax:
Practice Address - Street 1:910 BORDEAUX ST
Practice Address - Street 2:
Practice Address - City:CHADRON
Practice Address - State:NE
Practice Address - Zip Code:69337-2617
Practice Address - Country:US
Practice Address - Phone:308-327-2026
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-09
Last Update Date:2025-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE12717101YM0800X
NE3637101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health