Provider Demographics
NPI:1962577510
Name:GRIMOLIZZI-JENSEN, ANTONIA G (LISW)
Entity type:Individual
Prefix:MRS
First Name:ANTONIA
Middle Name:G
Last Name:GRIMOLIZZI-JENSEN
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:MRS
Other - First Name:ANTONIA
Other - Middle Name:G
Other - Last Name:JENSEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LISW
Mailing Address - Street 1:PO BOX 146
Mailing Address - Street 2:
Mailing Address - City:WAUSEON
Mailing Address - State:OH
Mailing Address - Zip Code:43567-0146
Mailing Address - Country:US
Mailing Address - Phone:419-335-6122
Mailing Address - Fax:419-318-4157
Practice Address - Street 1:1115 N SHOOP AVE
Practice Address - Street 2:
Practice Address - City:WAUSEON
Practice Address - State:OH
Practice Address - Zip Code:43567-1857
Practice Address - Country:US
Practice Address - Phone:419-335-6122
Practice Address - Fax:419-318-4157
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI72661041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0254416Medicaid