Healthcare Provider Details

I. General information

NPI: 1649184599
Provider Name (Legal Business Name): GRACE ELLIOTT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2026
Last Update Date: 09/29/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3395 AUSTRIAN PINE WAY APT 22
PORTAGE MI
49024
US

IV. Provider business mailing address

3395 AUSTRIAN PINE WAY APT 22
PORTAGE MI
49024
US

V. Phone/Fax

Practice location:
  • Phone: 269-967-6861
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: