Healthcare Provider Details

I. General information

NPI: 1801737986
Provider Name (Legal Business Name): DEJA LATRELL GRAYHEART
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2026
Last Update Date: 04/02/2026
Certification Date: 04/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5981 NW 21ST ST
LAUDERHILL FL
33313-7606
US

IV. Provider business mailing address

5981 NW 21ST ST
LAUDERHILL FL
33313-7606
US

V. Phone/Fax

Practice location:
  • Phone: 561-884-4085
  • Fax:
Mailing address:
  • Phone:
  • Fax: 561-884-4085

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: