Provider Demographics
NPI:1801950639
Name:GRANELLI, BRYAN F (PHD)
Entity type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:F
Last Name:GRANELLI
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14-25 PLAZA RD STE N27
Mailing Address - Street 2:
Mailing Address - City:FAIR LAWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07410-3548
Mailing Address - Country:US
Mailing Address - Phone:201-445-4310
Mailing Address - Fax:
Practice Address - Street 1:14-25 PLAZA RD STE N27
Practice Address - Street 2:
Practice Address - City:FAIR LAWN
Practice Address - State:NJ
Practice Address - Zip Code:07410-3548
Practice Address - Country:US
Practice Address - Phone:201-445-4310
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TA0400X
NJSI1942103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ45362Medicare ID - Type Unspecified