Healthcare Provider Details

I. General information

NPI: 1962122556
Provider Name (Legal Business Name): CINDY GRANADOS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/01/2022
Last Update Date: 04/29/2025
Certification Date: 04/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41 JORDAN DR
MEDFORD NY
11763-2050
US

IV. Provider business mailing address

41 JORDAN DR
MEDFORD NY
11763-2050
US

V. Phone/Fax

Practice location:
  • Phone: 631-882-0528
  • Fax:
Mailing address:
  • Phone: 631-774-6332
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number004192
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: