Basic Information
| Provider Information | |||||||||
| NPI: | 1003149766 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRAHAM | ||||||||
| FirstName: | RITA | ||||||||
| MiddleName: | RAE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | NCTMB | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1244 AMERICAN WAY | ||||||||
| Address2: | |||||||||
| City: | LIBERTYVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600483936 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475499595 | ||||||||
| FaxNumber: | 8475499596 | ||||||||
| Practice Location | |||||||||
| Address1: | 1244 AMERICAN WAY | ||||||||
| Address2: | |||||||||
| City: | LIBERTYVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600483936 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475499595 | ||||||||
| FaxNumber: | 8475499596 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2009 | ||||||||
| LastUpdateDate: | 09/14/2009 | ||||||||
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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 | 174400000X | 227008684 | IL | Y | Other Service Providers | Specialist |
No ID Information.