Healthcare Provider Details

I. General information

NPI: 1811496029
Provider Name (Legal Business Name): GRACE NJI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/03/2018
Last Update Date: 02/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23901 LAHSER RD
SOUTHFIELD MI
48033-6035
US

IV. Provider business mailing address

27321 NANTUCKET DR
SOUTHFIELD MI
48076-4871
US

V. Phone/Fax

Practice location:
  • Phone: 248-357-3360
  • Fax:
Mailing address:
  • Phone: 313-952-5502
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number5202007192
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: