Provider Demographics
NPI:1467106914
Name:GRANT, ELLEN M (NONE)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:M
Last Name:GRANT
Suffix:
Gender:F
Credentials:NONE
Other - Prefix:
Other - First Name:ELLEN
Other - Middle Name:MALINDA
Other - Last Name:DAWES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NONE
Mailing Address - Street 1:18726 S. WESTERN AVENUE, SUITE 408
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90248
Mailing Address - Country:US
Mailing Address - Phone:310-856-0800
Mailing Address - Fax:855-568-2494
Practice Address - Street 1:1149 W. 190TH STREET, SUITE 2200
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90248
Practice Address - Country:US
Practice Address - Phone:310-856-0800
Practice Address - Fax:855-568-2494
Is Sole Proprietor?:No
Enumeration Date:2022-02-03
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician