Provider Demographics
NPI:1134312655
Name:GRANT, LAKEITHA
Entity Type:Individual
Prefix:
First Name:LAKEITHA
Middle Name:
Last Name:GRANT
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 1:3011 W GRAND BLVD
Mailing Address - Street 2:STE 2000
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-3096
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3011 W GRAND BLVD
Practice Address - Street 2:STE 2000
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-3096
Practice Address - Country:US
Practice Address - Phone:800-972-4283
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-20
Last Update Date:2007-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801088086104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker