Healthcare Provider Details

I. General information

NPI: 1750851374
Provider Name (Legal Business Name): ANGELENA ALEXIS GRANT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANGELENA GRANT MA, BCBA, LBA

II. Dates (important events)

Enumeration Date: 11/26/2018
Last Update Date: 04/22/2026
Certification Date: 04/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12200 E 13 MILE RD STE 200
WARREN MI
48093-3093
US

IV. Provider business mailing address

825 CLINTON RIVER DR APT 9A
MOUNT CLEMENS MI
48043-7805
US

V. Phone/Fax

Practice location:
  • Phone: 586-573-1862
  • Fax:
Mailing address:
  • Phone: 770-882-9368
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number7401002329
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: