Provider Demographics
NPI:1528800539
Name:GRISSOMDARRISAW, MISCHA MARIE (MSW)
Entity type:Individual
Prefix:
First Name:MISCHA
Middle Name:MARIE
Last Name:GRISSOMDARRISAW
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 1:8954 W 35TH WAY
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33018-1893
Mailing Address - Country:US
Mailing Address - Phone:786-720-9625
Mailing Address - Fax:
Practice Address - Street 1:1527 NE 4TH AVE
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33304-1035
Practice Address - Country:US
Practice Address - Phone:954-835-5741
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-10
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker