Healthcare Provider Details

I. General information

NPI: 1114850898
Provider Name (Legal Business Name): ALEXIS DIANA GRANT PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2026
Last Update Date: 06/04/2026
Certification Date: 06/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 EDISON RD
ORANGE CT
06477-3602
US

IV. Provider business mailing address

66 VISTA TER
NEW HAVEN CT
06515-2402
US

V. Phone/Fax

Practice location:
  • Phone: 973-214-1951
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number028081-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: