Provider Demographics
NPI:1003973264
Name:GRUNBAUM, MELISSA JILL (LICSW)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:JILL
Last Name:GRUNBAUM
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:62 MOUNTAIN GATE RD
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:MA
Mailing Address - Zip Code:01721-2326
Mailing Address - Country:US
Mailing Address - Phone:508-309-3494
Mailing Address - Fax:
Practice Address - Street 1:780 AMERICAN LEGION HWY
Practice Address - Street 2:
Practice Address - City:ROSLINDALE
Practice Address - State:MA
Practice Address - Zip Code:02131-3908
Practice Address - Country:US
Practice Address - Phone:614-469-8616
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1131921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical