Provider Demographics
NPI:1760519862
Name:GRISWOLD, NICKI NAKESSA
Entity Type:Individual
Prefix:MRS
First Name:NICKI
Middle Name:NAKESSA
Last Name:GRISWOLD
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 1:2399 WHITE ST
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91107-3265
Mailing Address - Country:US
Mailing Address - Phone:626-796-8747
Mailing Address - Fax:
Practice Address - Street 1:15229 AMAR RD
Practice Address - Street 2:
Practice Address - City:LA PUENTE
Practice Address - State:CA
Practice Address - Zip Code:91744-2066
Practice Address - Country:US
Practice Address - Phone:626-855-5090
Practice Address - Fax:626-961-1810
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG0409281511101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)