Provider Demographics
NPI:1275639726
Name:GRISWOLD, SALLY JEAN (LCSW)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:JEAN
Last Name:GRISWOLD
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 PERRY ST
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:NY
Mailing Address - Zip Code:13021-2849
Mailing Address - Country:US
Mailing Address - Phone:315-412-3625
Mailing Address - Fax:315-253-5895
Practice Address - Street 1:18 PERRY ST
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:NY
Practice Address - Zip Code:13021-2849
Practice Address - Country:US
Practice Address - Phone:315-412-3625
Practice Address - Fax:315-253-5895
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-15
Last Update Date:2013-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY070548-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical