=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043845761
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MRS. EZRA GRENADE-CARABALLO
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/04/2020
-----------------------------------------------------
Last Update Date | 10/30/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 600 S WILBUR AVE
-----------------------------------------------------
City | SYRACUSE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13204-2730
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-476-7441
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 600 S WILBUR AVE
-----------------------------------------------------
City | SYRACUSE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13204-2730
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-498-1304
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 112484-01
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------