Provider Demographics
NPI:1740815075
Name:GRIZZLE, LAURA ELIZABETH
Entity type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:ELIZABETH
Last Name:GRIZZLE
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:LAURA
Other - Middle Name:ELIZABETH
Other - Last Name:WAGNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1118 S 7TH ST
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63104-3624
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1118 S 7TH ST
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104-3624
Practice Address - Country:US
Practice Address - Phone:314-477-2699
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-06
Last Update Date:2020-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool