Basic Information
| Provider Information | |||||||||
| NPI: | 1811295793 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRANT | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | BCBA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GRANT | ||||||||
| OtherFirstName: | LAURA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | BCBA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1026 DARROW AVE | ||||||||
| Address2: | |||||||||
| City: | EVANSTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 602021110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3179663300 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 7901 E 88TH ST | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462561235 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178495437 | ||||||||
| FaxNumber: | 3178425911 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2011 | ||||||||
| LastUpdateDate: | 05/27/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.