Provider Demographics
NPI:1457614802
Name:GRISWOLD, STEPHANIE R (PSYD)
Entity Type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:R
Last Name:GRISWOLD
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 S FAIRFIELD AVE
Mailing Address - Street 2:NR 5TH FLOOR
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60608-1782
Mailing Address - Country:US
Mailing Address - Phone:773-257-4750
Mailing Address - Fax:
Practice Address - Street 1:1500 S FAIRFIELD AVE
Practice Address - Street 2:NR 5TH FLOOR
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-1782
Practice Address - Country:US
Practice Address - Phone:773-257-4750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-20
Last Update Date:2016-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.008923103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical