Provider Demographics
NPI:1457751430
Name:GRISALVA, MISTY I (LMSW)
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:I
Last Name:GRISALVA
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 EAST NINTH AVENUE
Mailing Address - Street 2:
Mailing Address - City:TURTH OR CONSEQUENCES
Mailing Address - State:NM
Mailing Address - Zip Code:87901
Mailing Address - Country:US
Mailing Address - Phone:575-743-1205
Mailing Address - Fax:575-874-7659
Practice Address - Street 1:800 EAST NINTH AVENUE
Practice Address - Street 2:
Practice Address - City:TURTH OR CONSEQUENCES
Practice Address - State:NM
Practice Address - Zip Code:87901
Practice Address - Country:US
Practice Address - Phone:575-743-1205
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-27
Last Update Date:2014-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMX-08765104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker