MEDICARE: MALLORY GRIMSTE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1417444910
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MALLORY GRIMSTE LLC

Provider Business Mailing Address
First Line	:	250 W MAIN ST STE 203
Second Line	:
City	:	BRANFORD
State	:	CT
Zip	:	06405-4032
Country	:	US
Telephone Number	:	203-228-8971
Fax Number	:	203-429-8628

Provider Business Practice Location Address
First Line	:	30 HAZEL TER STE 12
Second Line	:
City	:	WOODBRIDGE
State	:	CT
Zip	:	06525-2240
Country	:	US
Telephone Number	:	203-228-8971
Fax Number	:	203-429-8628

Authorized Official
Title or Position	:	OWNER
Name	:	MALLORY ANNE GRIMSTE
Credential	:	LCSW
Telephone Number	:	203-228-8971

Provider Enumeration Date	:	04/19/2018
Last Update Date	:	12/12/2025

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