Provider Demographics
NPI:1689498313
Name:GRANT, KAELA JANELLE
Entity type:Individual
Prefix:
First Name:KAELA
Middle Name:JANELLE
Last Name:GRANT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2743 E TRAIL BLAZER DR
Mailing Address - Street 2:
Mailing Address - City:SAN TAN VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85140-0022
Mailing Address - Country:US
Mailing Address - Phone:480-544-1989
Mailing Address - Fax:
Practice Address - Street 1:37200 N GANTZEL RD STE 150
Practice Address - Street 2:
Practice Address - City:SAN TAN VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85140-7383
Practice Address - Country:US
Practice Address - Phone:520-484-1111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-11
Last Update Date:2024-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBEH-001570103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst