Healthcare Provider Details

I. General information

NPI: 1124632419
Provider Name (Legal Business Name): SYDNEY GRISHAM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/03/2020
Last Update Date: 10/05/2023
Certification Date: 10/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7010 E BOGARD RD
WASILLA AK
99654-4711
US

IV. Provider business mailing address

2521 E MOUNTAIN VILLAGE DR STE B
WASILLA AK
99654-7377
US

V. Phone/Fax

Practice location:
  • Phone: 907-373-4732
  • Fax:
Mailing address:
  • Phone: 907-521-8144
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: