Provider Demographics
NPI:1457775967
Name:SALLY GRISWOLD LCSW PLLC
Entity type:Organization
Organization Name:SALLY GRISWOLD LCSW PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SALLY
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:GRISWOLD
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW-R
Authorized Official - Phone:315-412-3625
Mailing Address - Street 1:18 PERRY ST
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:NY
Mailing Address - Zip Code:13021-2849
Mailing Address - Country:US
Mailing Address - Phone:315-412-3625
Mailing Address - Fax:315-253-5895
Practice Address - Street 1:18 PERRY ST
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:NY
Practice Address - Zip Code:13021-2849
Practice Address - Country:US
Practice Address - Phone:315-412-3625
Practice Address - Fax:315-253-5895
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-05
Last Update Date:2015-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY070548-1251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health