Provider Demographics
NPI:1659730695
Name:GRENNOR, CARLY (BCBA)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:GRENNOR
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1057
Mailing Address - Street 2:
Mailing Address - City:LAKE ALFRED
Mailing Address - State:FL
Mailing Address - Zip Code:33850-1057
Mailing Address - Country:US
Mailing Address - Phone:863-551-3300
Mailing Address - Fax:863-551-3301
Practice Address - Street 1:202 HOWARD ST
Practice Address - Street 2:
Practice Address - City:AUBURNDALE
Practice Address - State:FL
Practice Address - Zip Code:33823-3431
Practice Address - Country:US
Practice Address - Phone:863-551-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-18
Last Update Date:2016-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-15-21181103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst