Provider Demographics
NPI:1023288982
Name:GRANILLO SPEECH PATHOLOGY, PLLC
Entity type:Organization
Organization Name:GRANILLO SPEECH PATHOLOGY, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER/MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:KELLI
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:GRANILLO
Authorized Official - Suffix:
Authorized Official - Credentials:MS CCC/SLP
Authorized Official - Phone:702-235-3354
Mailing Address - Street 1:7461 COYOTE CAVE AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89113-3294
Mailing Address - Country:US
Mailing Address - Phone:702-235-3354
Mailing Address - Fax:
Practice Address - Street 1:3041 W HORIZON RIDGE PKWY
Practice Address - Street 2:SUITE 150
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-3948
Practice Address - Country:US
Practice Address - Phone:702-235-3354
Practice Address - Fax:702-920-8062
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-07
Last Update Date:2008-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVSP-1063235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty