Provider Demographics
NPI:1730268129
Name:GRAHAM, PENNY L
Entity type:Individual
Prefix:
First Name:PENNY
Middle Name:L
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 1:2109 HERNDON ST
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:FL
Mailing Address - Zip Code:33527-6349
Mailing Address - Country:US
Mailing Address - Phone:813-404-4142
Mailing Address - Fax:
Practice Address - Street 1:2109 HERNDON ST
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:FL
Practice Address - Zip Code:33527-6349
Practice Address - Country:US
Practice Address - Phone:813-404-4142
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist