Provider Demographics
NPI:1295365906
Name:GRIJALVA, KATHERYNE
Entity Type:Individual
Prefix:
First Name:KATHERYNE
Middle Name:
Last Name:GRIJALVA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 BEECHSTONE APT 5
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:NH
Mailing Address - Zip Code:03801-6321
Mailing Address - Country:US
Mailing Address - Phone:857-413-6055
Mailing Address - Fax:
Practice Address - Street 1:539 ISLINGTON ST STE 4
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:NH
Practice Address - Zip Code:03801-4471
Practice Address - Country:US
Practice Address - Phone:603-689-7890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-22
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
NH25561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3078870Medicaid