1982874798 NPI number — KELLI LYNN GRANILLO M.S. CCC/SLP

Table of content: KELLI LYNN GRANILLO M.S. CCC/SLP (NPI 1982874798)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982874798 NPI number — KELLI LYNN GRANILLO M.S. CCC/SLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRANILLO
Provider First Name:
KELLI
Provider Middle Name:
LYNN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.S. CCC/SLP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1982874798
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7461 COYOTE CAVE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAS VEGAS
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89113-3294
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-235-3354
Provider Business Mailing Address Fax Number:
702-920-8062

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3041 W HORIZON RIDGE PKWY
Provider Second Line Business Practice Location Address:
SUITE 150
Provider Business Practice Location Address City Name:
HENDERSON
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89052-3948
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-235-3354
Provider Business Practice Location Address Fax Number:
702-920-8062
Provider Enumeration Date:
03/07/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  SP-1063 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)