Provider Demographics
NPI:1750851374
Name:GRANT, ANGELENA ALEXIS
Entity Type:Individual
Prefix:
First Name:ANGELENA
Middle Name:ALEXIS
Last Name:GRANT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LENA
Other - Middle Name:
Other - Last Name:GRANT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2055 WATERCREST CIR
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-5444
Mailing Address - Country:US
Mailing Address - Phone:770-882-9368
Mailing Address - Fax:
Practice Address - Street 1:4390 PLEASANT HILL RD
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-8054
Practice Address - Country:US
Practice Address - Phone:866-610-0580
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-26
Last Update Date:2018-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician