Provider Demographics
NPI:1104659606
Name:GRANT, SHANEKA ROCHELLE
Entity type:Individual
Prefix:
First Name:SHANEKA
Middle Name:ROCHELLE
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 1:481 ELMA G MILES PKWY STE B
Mailing Address - Street 2:
Mailing Address - City:HINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31313-4004
Mailing Address - Country:US
Mailing Address - Phone:912-532-9774
Mailing Address - Fax:912-221-3085
Practice Address - Street 1:481 ELMA G MILES PKWY STE B
Practice Address - Street 2:
Practice Address - City:HINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:31313-4004
Practice Address - Country:US
Practice Address - Phone:912-532-9774
Practice Address - Fax:912-221-3085
Is Sole Proprietor?:No
Enumeration Date:2024-08-21
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARBT-24-351788106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician