Healthcare Provider Details

I. General information

NPI: 1316863038
Provider Name (Legal Business Name): GLORIA GRANILLO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2026
Last Update Date: 06/26/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13913 S WESTERN AVE
OKLAHOMA CITY OK
73170-7011
US

IV. Provider business mailing address

1129 SE 22ND ST
OKLAHOMA CITY OK
73129-6310
US

V. Phone/Fax

Practice location:
  • Phone: 405-445-5567
  • Fax: 405-761-4748
Mailing address:
  • Phone: 405-931-1652
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-26-548143
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: