Provider Demographics
NPI:1619592839
Name:GRANT, JANELLE LAVON
Entity Type:Individual
Prefix:
First Name:JANELLE
Middle Name:LAVON
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 1:2634 VILLAGE LN
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71112-2318
Mailing Address - Country:US
Mailing Address - Phone:318-617-9347
Mailing Address - Fax:
Practice Address - Street 1:2634 VILLAGE LN
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71112-2318
Practice Address - Country:US
Practice Address - Phone:318-617-9347
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-12
Last Update Date:2020-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XM0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistMental Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant