Provider Demographics
NPI:1689969008
Name:GRALL, AMBER LEE (BA SOCIAL WORK)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:LEE
Last Name:GRALL
Suffix:
Gender:F
Credentials:BA SOCIAL WORK
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3415 CUSTER ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-4356
Mailing Address - Country:US
Mailing Address - Phone:920-652-2440
Mailing Address - Fax:920-652-2441
Practice Address - Street 1:3415 CUSTER ST
Practice Address - Street 2:
Practice Address - City:MANITOWOC
Practice Address - State:WI
Practice Address - Zip Code:54220-4356
Practice Address - Country:US
Practice Address - Phone:920-652-2440
Practice Address - Fax:920-652-2441
Is Sole Proprietor?:No
Enumeration Date:2011-06-14
Last Update Date:2011-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10510-120171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator