Healthcare Provider Details

I. General information

NPI: 1104752963
Provider Name (Legal Business Name): BRIAN JOSUE GONZALEZ GRANADOS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2026
Last Update Date: 06/19/2026
Certification Date: 06/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5109 INFLUENCE WAY
RALEIGH NC
27616-4345
US

IV. Provider business mailing address

3904 BOOKER AVE
DURHAM NC
27713-1128
US

V. Phone/Fax

Practice location:
  • Phone: 919-239-4805
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number18541
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: