Provider Demographics
NPI:1659567592
Name:DEROCHA, GRACE (RD, CDE)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:DEROCHA
Suffix:
Gender:F
Credentials:RD, CDE
Other - Prefix:
Other - First Name:GRACE
Other - Middle Name:
Other - Last Name:ARRIOLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD, CDE
Mailing Address - Street 1:1333 BREWERY PARK BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48207-4544
Mailing Address - Country:US
Mailing Address - Phone:313-446-4444
Mailing Address - Fax:313-446-4445
Practice Address - Street 1:30158 TRAILWOOD DR
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48092-6304
Practice Address - Country:US
Practice Address - Phone:313-570-1166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-24
Last Update Date:2013-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI886178133V00000X
MI20920243174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No174H00000XOther Service ProvidersHealth Educator