Provider Demographics
NPI:1124295829
Name:GRIEPSMA, MALLARY ANN (MSW)
Entity type:Individual
Prefix:
First Name:MALLARY
Middle Name:ANN
Last Name:GRIEPSMA
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 WILSON ST
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NY
Mailing Address - Zip Code:14513-1946
Mailing Address - Country:US
Mailing Address - Phone:315-331-5364
Mailing Address - Fax:
Practice Address - Street 1:1519 NYE RD
Practice Address - Street 2:
Practice Address - City:LYONS
Practice Address - State:NY
Practice Address - Zip Code:14489-9133
Practice Address - Country:US
Practice Address - Phone:315-946-5722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-12
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00357502Medicaid