Healthcare Provider Details

I. General information

NPI: 1871786038
Provider Name (Legal Business Name): LESVY JACKELINE GRANILLO CADC-II CA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2007
Last Update Date: 04/02/2026
Certification Date: 04/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

909 N AVALON BLVD
WILMINGTON CA
90744-4503
US

IV. Provider business mailing address

909 N AVALON BLVD
WILMINGTON CA
90744-4503
US

V. Phone/Fax

Practice location:
  • Phone: 310-513-0626
  • Fax: 310-513-1311
Mailing address:
  • Phone: 310-513-0626
  • Fax: 310-513-1311

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberAII056590518
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: