Basic Information
| Provider Information | |||||||||
| NPI: | 1225565831 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRAHAM | ||||||||
| FirstName: | DEONNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 528 | ||||||||
| Address2: | ATTN: BH DD SERVICES | ||||||||
| City: | BETHEL | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995590528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9075432762 | ||||||||
| FaxNumber: | 9075433152 | ||||||||
| Practice Location | |||||||||
| Address1: | 460 RIDGECREST DRIVE | ||||||||
| Address2: | SUITE 214 | ||||||||
| City: | BETHEL | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995590528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9075432762 | ||||||||
| FaxNumber: | 9075433152 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2017 | ||||||||
| LastUpdateDate: | 05/12/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 373H00000X | Y | Nursing Service Related Providers | Day Training/Habilitation Specialist |
ID Information
| ID | Type | State | Issuer | Description | 1002447 | 05 | AK | MEDICAID |