Provider Demographics
NPI:1114058245
Name:GRISHAM, GAYLA KAY (LBSW)
Entity Type:Individual
Prefix:MS
First Name:GAYLA
Middle Name:KAY
Last Name:GRISHAM
Suffix:
Gender:F
Credentials:LBSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:421 VILLA DRIVE #209
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76710
Mailing Address - Country:US
Mailing Address - Phone:254-405-2702
Mailing Address - Fax:866-686-9651
Practice Address - Street 1:421 VILLA DRIVE #209
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76710
Practice Address - Country:US
Practice Address - Phone:254-405-2702
Practice Address - Fax:866-686-9651
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2007-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX339661041C0700X, 171M00000X, 251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX182405401Medicaid
TX182404701Medicaid