Basic Information
| Provider Information | |||||||||
| NPI: | 1023574035 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRAHAM | ||||||||
| FirstName: | KIERA | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3445 GREEN RD | ||||||||
| Address2: | |||||||||
| City: | BEACHWOOD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441227708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2163153592 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10427 DETROIT AVE | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441021645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2166947200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2019 | ||||||||
| LastUpdateDate: | 01/24/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | C1902382 | OH | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 1023574035 | 05 | OH | MEDICAID |