Provider Demographics
NPI:1821745274
Name:GRANADOS, DIMANIQUE T
Entity Type:Individual
Prefix:
First Name:DIMANIQUE
Middle Name:T
Last Name:GRANADOS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 SE 47TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73129-5328
Mailing Address - Country:US
Mailing Address - Phone:580-471-3476
Mailing Address - Fax:
Practice Address - Street 1:13821 TECHNOLOGY DR # A1
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73134-1045
Practice Address - Country:US
Practice Address - Phone:539-777-0940
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-06
Last Update Date:2022-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician