Provider Demographics
NPI:1699816165
Name:GRIESE, CYNTHIA A (CADC III,CCS II)
Entity type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:A
Last Name:GRIESE
Suffix:
Gender:F
Credentials:CADC III,CCS II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4680 LAKE RD
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54902-7500
Mailing Address - Country:US
Mailing Address - Phone:920-235-3521
Mailing Address - Fax:
Practice Address - Street 1:1201 TUCKAWAY LN
Practice Address - Street 2:
Practice Address - City:MENASHA
Practice Address - State:WI
Practice Address - Zip Code:54952-1704
Practice Address - Country:US
Practice Address - Phone:920-733-4443
Practice Address - Fax:920-733-4796
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1888101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39360500Medicaid