Provider Demographics
NPI:1104334762
Name:GRANT, KALEY D (MA, BCBA)
Entity type:Individual
Prefix:
First Name:KALEY
Middle Name:D
Last Name:GRANT
Suffix:
Gender:F
Credentials:MA, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11551 LAKESIDE DR APT 7401
Mailing Address - Street 2:
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33178-3022
Mailing Address - Country:US
Mailing Address - Phone:406-459-9533
Mailing Address - Fax:
Practice Address - Street 1:7232 SW 39TH TER
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33155-6624
Practice Address - Country:US
Practice Address - Phone:786-229-0603
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-17
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-20-42520103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL102804200Medicaid