Provider Demographics
NPI:1174518831
Name:GRAHAM, SALLY (PHD)
Entity type:Individual
Prefix:DR
First Name:SALLY
Middle Name:
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 E 14TH ST
Mailing Address - Street 2:1410
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10003-3122
Mailing Address - Country:US
Mailing Address - Phone:212-803-5412
Mailing Address - Fax:
Practice Address - Street 1:24 E 12TH ST
Practice Address - Street 2:601A
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-4403
Practice Address - Country:US
Practice Address - Phone:212-807-0543
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-19
Last Update Date:2007-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYNY005618103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AD001971OtherAPA
NY01136429Medicaid
V40001Medicare ID - Type Unspecified