Healthcare Provider Details

I. General information

NPI: 1669117529
Provider Name (Legal Business Name): DOMINIQUE GRANT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2022
Last Update Date: 05/04/2022
Certification Date: 05/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9027 SUTPHIN BLVD
JAMAICA NY
11435-3647
US

IV. Provider business mailing address

8724 MIDLAND PKWY APT 4D
JAMAICA NY
11432-4758
US

V. Phone/Fax

Practice location:
  • Phone: 718-526-8400
  • Fax:
Mailing address:
  • Phone: 347-863-7773
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: