Healthcare Provider Details

I. General information

NPI: 1508369455
Provider Name (Legal Business Name): ANGELA MARIE GRANTHAM OTRL, CHT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2018
Last Update Date: 03/17/2025
Certification Date: 03/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 E MICHIGAN AVE STE 320
JACKSON MI
49201-1854
US

IV. Provider business mailing address

1201 E MICHIGAN AVE STE 320
JACKSON MI
49201-1854
US

V. Phone/Fax

Practice location:
  • Phone: 517-205-3897
  • Fax: 517-205-7634
Mailing address:
  • Phone: 517-205-3897
  • Fax: 517-817-7634

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number5201001150
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: