MEDICARE: MICHELLE SARENE GRANDBERRY QMHS BA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	172V00000X	Community Health Worker
2	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1821589425
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHELLE SARENE GRANDBERRY QMHS BA

Provider Business Mailing Address
First Line	:	12395 MCCRACKEN RD STE H
Second Line	:
City	:	GARFIELD HTS
State	:	OH
Zip	:	44125-2946
Country	:	US
Telephone Number	:	216-587-6727
Fax Number	:

Provider Business Practice Location Address
First Line	:	12395 MCCRACKEN RD STE H
Second Line	:
City	:	GARFIELD HTS
State	:	OH
Zip	:	44125-2946
Country	:	US
Telephone Number	:	216-587-6727
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/21/2018
Last Update Date	:	11/25/2022

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