MEDICARE: DOMINIQUE MICHELLE GRANT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1306799903
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DOMINIQUE MICHELLE GRANT

Provider Business Mailing Address
First Line	:	300 INTERNATIONAL PKWY STE 200
Second Line	:
City	:	LAKE MARY
State	:	FL
Zip	:	32746-5028
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1535 W NASA BLVD UNIT C-1
Second Line	:
City	:	MELBOURNE
State	:	FL
Zip	:	32901-2614
Country	:	US
Telephone Number	:	321-235-6199
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/16/2026
Last Update Date	:	02/16/2026

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Directions to “ DOMINIQUE MICHELLE GRANT ” Practice Location

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