Provider Demographics
NPI:1689706335
Name:GRISWOLD, ANN MARI G (LCSW)
Entity Type:Individual
Prefix:
First Name:ANN MARI
Middle Name:G
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 1:1366 STATE ROAD 164
Mailing Address - Street 2:
Mailing Address - City:HUBERTUS
Mailing Address - State:WI
Mailing Address - Zip Code:53033-9426
Mailing Address - Country:US
Mailing Address - Phone:262-628-2517
Mailing Address - Fax:
Practice Address - Street 1:W156N8327 PILGRIM RD
Practice Address - Street 2:
Practice Address - City:MENOMONEE FALLS
Practice Address - State:WI
Practice Address - Zip Code:53051-3776
Practice Address - Country:US
Practice Address - Phone:262-251-1112
Practice Address - Fax:262-251-1113
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI826-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI18003623002Medicaid