Provider Demographics
NPI:1730314428
Name:GRANADOS, SELENA MARIE (PSYD)
Entity Type:Individual
Prefix:MISS
First Name:SELENA
Middle Name:MARIE
Last Name:GRANADOS
Suffix:
Gender:F
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:PO BOX 1776
Mailing Address - Street 2:
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91722-0776
Mailing Address - Country:US
Mailing Address - Phone:619-318-6024
Mailing Address - Fax:
Practice Address - Street 1:1050 LAKES DR STE 225
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790-2910
Practice Address - Country:US
Practice Address - Phone:626-373-8384
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-25
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY33248103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical