Healthcare Provider Details

I. General information

NPI: 1003703455
Provider Name (Legal Business Name): KALA MICHELLE GRANT CLC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2025
Last Update Date: 06/19/2025
Certification Date: 06/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 COLUMBIANA DR STE 116
IRMO SC
29063-7782
US

IV. Provider business mailing address

1105 JOSEPH WESLEY RD
COLUMBIA SC
29209-9484
US

V. Phone/Fax

Practice location:
  • Phone: 803-250-5723
  • Fax:
Mailing address:
  • Phone: 336-251-7344
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: