Provider Demographics
NPI:1275170375
Name:GRANO, KENNETH (CFBPCA)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:GRANO
Suffix:
Gender:M
Credentials:CFBPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 NEILL RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:MATTHEWS
Mailing Address - State:NC
Mailing Address - Zip Code:28105-2031
Mailing Address - Country:US
Mailing Address - Phone:980-210-5800
Mailing Address - Fax:
Practice Address - Street 1:17830 STATESVILLE RD STE 235
Practice Address - Street 2:
Practice Address - City:CORNELIUS
Practice Address - State:NC
Practice Address - Zip Code:28031-8193
Practice Address - Country:US
Practice Address - Phone:704-620-7437
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-08
Last Update Date:2019-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC115101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral