Provider Demographics
NPI:1023334083
Name:GRANO DE ORO FAMILY MENTAL HEALTH SERVICES
Entity type:Organization
Organization Name:GRANO DE ORO FAMILY MENTAL HEALTH SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RODOLFO
Authorized Official - Middle Name:FIDENCIO
Authorized Official - Last Name:GRANO
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:505-617-6313
Mailing Address - Street 1:PO BOX 1856
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NM
Mailing Address - Zip Code:87701-1856
Mailing Address - Country:US
Mailing Address - Phone:505-617-6313
Mailing Address - Fax:
Practice Address - Street 1:1920 7TH ST
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NM
Practice Address - Zip Code:87701-4956
Practice Address - Country:US
Practice Address - Phone:505-617-6313
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-15
Last Update Date:2010-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0811103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM17480221Medicaid
NM301219OtherMEDICARE
NM1356452981OtherNPI