Healthcare Provider Details

I. General information

NPI: 1073058897
Provider Name (Legal Business Name): LORI GRANADO LBSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2017
Last Update Date: 01/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1718 YALE BLVD SE
ALBUQUERQUE NM
87106-4286
US

IV. Provider business mailing address

11800 MONTGOMERY BLVD NE APT 2066
ALBUQUERQUE NM
87111-2773
US

V. Phone/Fax

Practice location:
  • Phone: 505-242-3118
  • Fax: 505-242-3062
Mailing address:
  • Phone: 505-242-3118
  • Fax: 505-242-2306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License NumberB-09668
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: