Provider Demographics
NPI:1326705443
Name:GRANUM, LEE D
Entity Type:Individual
Prefix:
First Name:LEE
Middle Name:D
Last Name:GRANUM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:ROCKY
Other - Middle Name:N/A
Other - Last Name:N/A
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1751 2ND AVE APT 16A
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10128-5378
Mailing Address - Country:US
Mailing Address - Phone:571-474-4921
Mailing Address - Fax:
Practice Address - Street 1:41 UNION SQ W STE 1328
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-3252
Practice Address - Country:US
Practice Address - Phone:917-225-1401
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-23
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor