1689706335 NPI number — ANN MARI G GRISWOLD LCSW

Table of content: ANN MARI G GRISWOLD LCSW (NPI 1689706335)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689706335 NPI number — ANN MARI G GRISWOLD LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRISWOLD
Provider First Name:
ANN MARI
Provider Middle Name:
G
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1689706335
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1366 STATE ROAD 164
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HUBERTUS
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53033-9426
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
262-628-2517
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
W156N8327 PILGRIM RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MENOMONEE FALLS
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53051-3776
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-251-1112
Provider Business Practice Location Address Fax Number:
262-251-1113
Provider Enumeration Date:
03/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  826-123 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 18003623002 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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