MEDICARE: LESVY JACKELINE GRANILLO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor

General Provider Information

NPI Number	:	1871786038
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LESVY JACKELINE GRANILLO

Provider Business Mailing Address
First Line	:	14240 EAST IMPERIAL HWY
Second Line	:
City	:	LA MIRADA
State	:	CA
Zip	:	90638-8123
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	14240 EAST IMPERIAL HWY
Second Line	:
City	:	LA MIRADA
State	:	CA
Zip	:	90638-8123
Country	:	US
Telephone Number	:	562-946-1587
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/21/2007
Last Update Date	:	10/08/2014

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