Provider Demographics
NPI:1649757956
Name:GRANT, CHENELLE
Entity Type:Individual
Prefix:
First Name:CHENELLE
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 1:4670 LIPSCOMB ST NE STE 10
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32905-2927
Mailing Address - Country:US
Mailing Address - Phone:813-906-6203
Mailing Address - Fax:
Practice Address - Street 1:4670 LIPSCOMB ST NE STE 10
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32905-2927
Practice Address - Country:US
Practice Address - Phone:813-906-6203
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-19
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL103K00000X
FL1-21-51835103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL104507400Medicaid