Healthcare Provider Details

I. General information

NPI: 1144957101
Provider Name (Legal Business Name): MARLA GRESHAM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2022
Last Update Date: 08/01/2022
Certification Date: 08/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4646 JOHN R ST
DETROIT MI
48201-1916
US

IV. Provider business mailing address

18444 MIDDLESEX AVE
LATHRUP VILLAGE MI
48076-4516
US

V. Phone/Fax

Practice location:
  • Phone: 313-576-4836
  • Fax:
Mailing address:
  • Phone: 248-895-8689
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number4704186857
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: