Healthcare Provider Details

I. General information

NPI: 1659667293
Provider Name (Legal Business Name): MIRA GRACE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2011
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43191 DALCOMA DR STE 101
CLINTON TOWNSHIP MI
48038-6308
US

IV. Provider business mailing address

43191 DALCOMA DR STE 101
CLINTON TOWNSHIP MI
48038-6308
US

V. Phone/Fax

Practice location:
  • Phone: 248-810-4727
  • Fax: 248-810-4727
Mailing address:
  • Phone: 248-810-4727
  • Fax: 248-810-4727

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number4301507706
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: