Provider Demographics
NPI:1841591609
Name:GRIMSTE, MALLORY ANNE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:MALLORY
Middle Name:ANNE
Last Name:GRIMSTE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 HAZEL TER
Mailing Address - Street 2:SUITE 12
Mailing Address - City:WOODBRIDGE
Mailing Address - State:CT
Mailing Address - Zip Code:06525-2240
Mailing Address - Country:US
Mailing Address - Phone:203-228-8971
Mailing Address - Fax:203-429-8628
Practice Address - Street 1:30 HAZEL TER
Practice Address - Street 2:SUITE 12
Practice Address - City:WOODBRIDGE
Practice Address - State:CT
Practice Address - Zip Code:06525-2240
Practice Address - Country:US
Practice Address - Phone:203-228-8971
Practice Address - Fax:203-429-8628
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-10
Last Update Date:2015-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker