Healthcare Provider Details

I. General information

NPI: 1073295424
Provider Name (Legal Business Name): KODA LYNNE GRASL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: OLIVIA LYNNE GRASL

II. Dates (important events)

Enumeration Date: 08/04/2023
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15600 19 MILE RD
CLINTON TOWNSHIP MI
48038-3502
US

IV. Provider business mailing address

2695 GREENSTONE BLVD APT 1102
AUBURN HILLS MI
48326-3771
US

V. Phone/Fax

Practice location:
  • Phone: 586-263-8700
  • Fax:
Mailing address:
  • Phone: 586-216-3231
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6851122409
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: