Healthcare Provider Details

I. General information

NPI: 1861512501
Provider Name (Legal Business Name): LEIGH KAROLE GRANNAN M.S., BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 11/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 WHAM DR - MAILCODE 6607 CENTER FOR AUTISM SPECTRUM DISORDERS
CARBONDALE IL
62901-4313
US

IV. Provider business mailing address

60 JAROS LN APT F
MAKANDA IL
62958-2154
US

V. Phone/Fax

Practice location:
  • Phone: 618-453-7168
  • Fax:
Mailing address:
  • Phone: 618-967-8859
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-04-1782
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: