Provider Demographics
NPI:1649997529
Name:GRIZKY, KATHLEEN (LCADC, CCS)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:GRIZKY
Suffix:
Gender:F
Credentials:LCADC, CCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:DOROTHY
Mailing Address - State:NJ
Mailing Address - Zip Code:08317-9734
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:DOROTHY
Practice Address - State:NJ
Practice Address - Zip Code:08317-9734
Practice Address - Country:US
Practice Address - Phone:609-364-1255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-21
Last Update Date:2022-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37LC00293200101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)