Provider Demographics
NPI:1083160758
Name:GRIFFIN, CLARICE BEATRICE
Entity Type:Individual
Prefix:MRS
First Name:CLARICE
Middle Name:BEATRICE
Last Name:GRIFFIN
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:CLARICE
Other - Middle Name:BEATRICE
Other - Last Name:BLAKELY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3809 SWAN RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:TN
Mailing Address - Zip Code:37013-2095
Mailing Address - Country:US
Mailing Address - Phone:434-251-9751
Mailing Address - Fax:
Practice Address - Street 1:3809 SWAN RIDGE DR
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:TN
Practice Address - Zip Code:37013-2095
Practice Address - Country:US
Practice Address - Phone:434-251-9751
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-31
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3397960Medicaid