Provider Demographics
NPI:1235618703
Name:GRUDINSKI, MELISSA MARIE (LICSW)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:MARIE
Last Name:GRUDINSKI
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 1:2013 ELM ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03104-2528
Mailing Address - Country:US
Mailing Address - Phone:603-627-2702
Mailing Address - Fax:603-627-3463
Practice Address - Street 1:2013 ELM ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03104-2528
Practice Address - Country:US
Practice Address - Phone:603-627-2702
Practice Address - Fax:603-627-3463
Is Sole Proprietor?:No
Enumeration Date:2018-08-07
Last Update Date:2018-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
NH1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)