Basic Information
| Provider Information | |||||||||
| NPI: | 1720244163 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRAHAM | ||||||||
| FirstName: | JUSTIN | ||||||||
| MiddleName: | DONALD | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6363 FRANCE AVE S STE 200 | ||||||||
| Address2: | |||||||||
| City: | EDINA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554352140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9522309100 | ||||||||
| FaxNumber: | 9529222525 | ||||||||
| Practice Location | |||||||||
| Address1: | 6363 FRANCE AVE S STE 200 | ||||||||
| Address2: | |||||||||
| City: | EDINA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554352140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9522309100 | ||||||||
| FaxNumber: | 9529222525 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2008 | ||||||||
| LastUpdateDate: | 09/25/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0804X | 52451 | MN | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry |
No ID Information.