Provider Demographics
NPI:1881422236
Name:GRISSO, MATTHEW JARED (SUDCC)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JARED
Last Name:GRISSO
Suffix:
Gender:M
Credentials:SUDCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:CA
Mailing Address - Zip Code:94544-1948
Mailing Address - Country:US
Mailing Address - Phone:510-886-8696
Mailing Address - Fax:
Practice Address - Street 1:107 JACKSON ST
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:CA
Practice Address - Zip Code:94544-1948
Practice Address - Country:US
Practice Address - Phone:510-886-8696
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-25
Last Update Date:2024-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10070101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)