Healthcare Provider Details

I. General information

NPI: 1972316990
Provider Name (Legal Business Name): MS. MARY LISA GRANGER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/31/2025
Last Update Date: 01/31/2025
Certification Date: 01/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 TOWN CTR STE 1350
SOUTHFIELD MI
48075-1427
US

IV. Provider business mailing address

1289 E WALTON BLVD APT 210
PONTIAC MI
48340-1570
US

V. Phone/Fax

Practice location:
  • Phone: 586-339-2178
  • Fax:
Mailing address:
  • Phone: 313-544-0466
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: