Provider Demographics
NPI:1730416348
Name:GRAHAM, THERESA ANN
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:ANN
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:ANN
Other - Last Name:CORDERO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 82819
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97282-0819
Mailing Address - Country:US
Mailing Address - Phone:503-233-5405
Mailing Address - Fax:503-233-2692
Practice Address - Street 1:880 82ND DR
Practice Address - Street 2:
Practice Address - City:GLADSTONE
Practice Address - State:OR
Practice Address - Zip Code:97027-1803
Practice Address - Country:US
Practice Address - Phone:503-659-5515
Practice Address - Fax:503-659-1994
Is Sole Proprietor?:No
Enumeration Date:2009-11-03
Last Update Date:2010-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC2127101YP2500X
WALH00011236101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health