MEDICARE: LEICY MARIBI GRANADILLO CARROZ

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1255297164
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LEICY MARIBI GRANADILLO CARROZ

Provider Business Mailing Address
First Line	:	5146 ROYAL POINT AVE
Second Line	:
City	:	KISSIMMEE
State	:	FL
Zip	:	34746-6776
Country	:	US
Telephone Number	:	863-270-1339
Fax Number	:

Provider Business Practice Location Address
First Line	:	2243 NORTH BLVD W
Second Line	:
City	:	DAVENPORT
State	:	FL
Zip	:	33837-8990
Country	:	US
Telephone Number	:	863-270-1339
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/05/2026
Last Update Date	:	01/05/2026

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Directions to “ LEICY MARIBI GRANADILLO CARROZ ” Practice Location

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