Provider Demographics
NPI:1235329699
Name:GRISSOM, ANJA LEE (MED & LPC)
Entity Type:Individual
Prefix:MRS
First Name:ANJA
Middle Name:LEE
Last Name:GRISSOM
Suffix:
Gender:F
Credentials:MED & LPC
Other - Prefix:MS
Other - First Name:ANJA
Other - Middle Name:LEE
Other - Last Name:HEIDGERKEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:527 W 3RD ST
Mailing Address - Street 2:
Mailing Address - City:KONAWA
Mailing Address - State:OK
Mailing Address - Zip Code:74849-1415
Mailing Address - Country:US
Mailing Address - Phone:580-925-3286
Mailing Address - Fax:580-925-2362
Practice Address - Street 1:527 W 3RD ST
Practice Address - Street 2:
Practice Address - City:KONAWA
Practice Address - State:OK
Practice Address - Zip Code:74849-1415
Practice Address - Country:US
Practice Address - Phone:580-925-3286
Practice Address - Fax:580-925-2362
Is Sole Proprietor?:No
Enumeration Date:2007-07-31
Last Update Date:2010-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2478101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK2478OtherOK STATE DEPT OF HLTH