Provider Demographics
NPI:1740667104
Name:GRISWOLD-DODGSON, TERRI LARAE
Entity type:Individual
Prefix:
First Name:TERRI
Middle Name:LARAE
Last Name:GRISWOLD-DODGSON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 MACK ST
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435-5923
Mailing Address - Country:US
Mailing Address - Phone:417-343-0373
Mailing Address - Fax:
Practice Address - Street 1:601 MACK ST
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-5923
Practice Address - Country:US
Practice Address - Phone:417-343-0373
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-05
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12903813-6004101YP2500X
WALH61409067101YP2500X
IL180.010917101YP2500X
MT49347.101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional