Provider Demographics
NPI:1013137033
Name:GRIGWAY, CRYSTAL LEE (BA)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:LEE
Last Name:GRIGWAY
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 PRINCESS ST
Mailing Address - Street 2:APT # 2
Mailing Address - City:WAKEFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01880-3003
Mailing Address - Country:US
Mailing Address - Phone:781-968-5179
Mailing Address - Fax:
Practice Address - Street 1:103 JOHNSON ST
Practice Address - Street 2:
Practice Address - City:LYNN
Practice Address - State:MA
Practice Address - Zip Code:01902-4001
Practice Address - Country:US
Practice Address - Phone:781-593-2727
Practice Address - Fax:781-593-2542
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA416465222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist