Provider Demographics
NPI:1649983271
Name:GRANGE, MARIAH LEE (AUD)
Entity type:Individual
Prefix:
First Name:MARIAH
Middle Name:LEE
Last Name:GRANGE
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 E MICHIGAN AVE STE 330
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48912-1894
Mailing Address - Country:US
Mailing Address - Phone:517-364-5678
Mailing Address - Fax:
Practice Address - Street 1:1200 E MICHIGAN AVE STE 330
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48912-1894
Practice Address - Country:US
Practice Address - Phone:517-364-5678
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-28
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1601001091231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist