Provider Demographics
NPI:1649870759
Name:GRANDE, MIKAELA EMILY (BCBA)
Entity type:Individual
Prefix:
First Name:MIKAELA
Middle Name:EMILY
Last Name:GRANDE
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:331 DORN AVE
Mailing Address - Street 2:
Mailing Address - City:MIDDLESEX
Mailing Address - State:NJ
Mailing Address - Zip Code:08846-1117
Mailing Address - Country:US
Mailing Address - Phone:732-339-3100
Mailing Address - Fax:
Practice Address - Street 1:331 DORN AVE
Practice Address - Street 2:
Practice Address - City:MIDDLESEX
Practice Address - State:NJ
Practice Address - Zip Code:08846
Practice Address - Country:US
Practice Address - Phone:732-339-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-28
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ1-20-44743103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst