Healthcare Provider Details

I. General information

NPI: 1255955266
Provider Name (Legal Business Name): SELENAANN MILICANT KRISTINE GRISWOLD MSW, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SELENAANN MILICANT KRISTINE BALDWIN

II. Dates (important events)

Enumeration Date: 06/04/2020
Last Update Date: 04/27/2023
Certification Date: 04/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 W SWANSON AVE
WASILLA AK
99654-6822
US

IV. Provider business mailing address

7362 W PARKS HWY # 339
WASILLA AK
99623-9300
US

V. Phone/Fax

Practice location:
  • Phone: 907-671-2884
  • Fax: 907-600-5102
Mailing address:
  • Phone: 907-671-2884
  • Fax: 907-600-5102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number179516
License Number StateAK

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: