Provider Demographics
NPI:1255171633
Name:GRISSOM, SAMARA
Entity type:Individual
Prefix:
First Name:SAMARA
Middle Name:
Last Name:GRISSOM
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 1:1019 FRANKLIN ST APT 1
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:IN
Mailing Address - Zip Code:47201-5786
Mailing Address - Country:US
Mailing Address - Phone:812-341-7615
Mailing Address - Fax:
Practice Address - Street 1:4070 25TH ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47203-3161
Practice Address - Country:US
Practice Address - Phone:812-373-6103
Practice Address - Fax:888-375-4149
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-31
Last Update Date:2024-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INRBT-21-188553106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician