Provider Demographics
NPI:1730181447
Name:GRAHAM, SAMUEL LEE (PHD)
Entity type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:LEE
Last Name:GRAHAM
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 1:1000 73RD ST
Mailing Address - Street 2:
Mailing Address - City:WINDSOR HEIGHTS
Mailing Address - State:IA
Mailing Address - Zip Code:50311-1321
Mailing Address - Country:US
Mailing Address - Phone:515-222-1175
Mailing Address - Fax:515-222-0953
Practice Address - Street 1:1000 73RD ST
Practice Address - Street 2:
Practice Address - City:WINDSOR HEIGHTS
Practice Address - State:IA
Practice Address - Zip Code:50311-1321
Practice Address - Country:US
Practice Address - Phone:515-222-1175
Practice Address - Fax:515-222-0953
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA435/160103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA421355536-26Medicaid
IA06512Medicare ID - Type Unspecified
IA421355536-26Medicaid