Provider Demographics
NPI:1356452981
Name:GRANO, RUDY FIDENCIO (PSYD)
Entity Type:Individual
Prefix:
First Name:RUDY
Middle Name:FIDENCIO
Last Name:GRANO
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:213 PLAZA ST
Mailing Address - Street 2:P.O. BOX 1856
Mailing Address - City:LAS VEGAS
Mailing Address - State:NM
Mailing Address - Zip Code:87701-3432
Mailing Address - Country:US
Mailing Address - Phone:505-617-6313
Mailing Address - Fax:505-617-6313
Practice Address - Street 1:213 PLAZA ST
Practice Address - Street 2:N/A
Practice Address - City:LAS VEGAS
Practice Address - State:NM
Practice Address - Zip Code:87701-3432
Practice Address - Country:US
Practice Address - Phone:505-617-6313
Practice Address - Fax:505-617-6313
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2013-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0811103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM17480221Medicaid