Healthcare Provider Details

I. General information

NPI: 1780312660
Provider Name (Legal Business Name): MARISA SIERRA GRIM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2022
Last Update Date: 03/27/2026
Certification Date: 03/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30000 HIVELEY ST
INKSTER MI
48141-1089
US

IV. Provider business mailing address

35280 FLORENCE ST
WESTLAND MI
48185-3609
US

V. Phone/Fax

Practice location:
  • Phone: 734-261-1842
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6851118306
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: