Provider Demographics
NPI:1982874798
Name:GRANILLO, KELLI LYNN (MS CCC/SLP)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:LYNN
Last Name:GRANILLO
Suffix:
Gender:F
Credentials:MS CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7461 COYOTE CAVE AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89113-3294
Mailing Address - Country:US
Mailing Address - Phone:702-235-3354
Mailing Address - Fax:702-920-8062
Practice Address - Street 1:3041 W HORIZON RIDGE PKWY
Practice Address - Street 2:SUITE 150
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-3948
Practice Address - Country:US
Practice Address - Phone:702-235-3354
Practice Address - Fax:702-920-8062
Is Sole Proprietor?:No
Enumeration Date:2008-03-07
Last Update Date:2008-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVSP-1063235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist