Provider Demographics
NPI:1861512501
Name:GRANNAN, LEIGH KAROLE (MS, BCBA)
Entity type:Individual
Prefix:MS
First Name:LEIGH
Middle Name:KAROLE
Last Name:GRANNAN
Suffix:
Gender:F
Credentials:MS, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 JAROS LN
Mailing Address - Street 2:APT F
Mailing Address - City:MAKANDA
Mailing Address - State:IL
Mailing Address - Zip Code:62958-2154
Mailing Address - Country:US
Mailing Address - Phone:618-967-8859
Mailing Address - Fax:
Practice Address - Street 1:625 WHAM DR - MAILCODE 6607
Practice Address - Street 2:CENTER FOR AUTISM SPECTRUM DISORDERS
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-4313
Practice Address - Country:US
Practice Address - Phone:618-453-7168
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-04-1782103K00000X
171000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No171000000XOther Service ProvidersMilitary Health Care Provider