Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225XM0800X | Mental Health |
NPI | 1619592839 |
---|---|
Provider Name | Janelle Lavon Grant |
First Address | Bossier City, LA 71112-2318 |
Second Address | Bossier City, LA 71112-2318 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 12/06/2020 |
Last Update Date | 01/07/2020 |