MEDICARE: SUSANNAH BORN-GRISSOM

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	101YM0800X	Mental Health Counselor

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1730532441
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSANNAH BORN-GRISSOM

Provider Business Mailing Address
First Line	:	3915 GRAMERCY AVE
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89031-2038
Country	:	US
Telephone Number	:	702-628-2968
Fax Number	:

Provider Business Practice Location Address
First Line	:	3915 GRAMERCY AVE
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89031-2038
Country	:	US
Telephone Number	:	702-628-2968
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/18/2016
Last Update Date	:	07/18/2016

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