Provider Demographics
NPI:1265229561
Name:GRANT, DOMINIQUE DENISE
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:DENISE
Last Name:GRANT
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:DOMINIQUE
Other - Middle Name:DENISE
Other - Last Name:BOYD-MILES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1011 W 29TH ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46208-4906
Mailing Address - Country:US
Mailing Address - Phone:317-533-0710
Mailing Address - Fax:
Practice Address - Street 1:9905 FALL CREEK RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46256-4804
Practice Address - Country:US
Practice Address - Phone:317-813-4690
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-22
Last Update Date:2025-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician