Provider Demographics
NPI:1972316990
Name:GRANGER, MARY LISA
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:LISA
Last Name:GRANGER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1289 E WALTON BLVD APT 210
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:MI
Mailing Address - Zip Code:48340-1570
Mailing Address - Country:US
Mailing Address - Phone:313-544-0466
Mailing Address - Fax:
Practice Address - Street 1:4000 TOWN CTR STE 1350
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-1427
Practice Address - Country:US
Practice Address - Phone:586-339-2178
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-31
Last Update Date:2025-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X
MI172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172V00000XOther Service ProvidersCommunity Health Worker