Healthcare Provider Details

I. General information

NPI: 1841591609
Provider Name (Legal Business Name): MALLORY ANNE GRIMSTE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2010
Last Update Date: 10/06/2025
Certification Date: 10/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 W MAIN ST STE 203
BRANFORD CT
06405-4032
US

IV. Provider business mailing address

250 W MAIN ST STE 203
BRANFORD CT
06405-4032
US

V. Phone/Fax

Practice location:
  • Phone: 203-228-8971
  • Fax: 203-429-8628
Mailing address:
  • Phone: 203-228-8971
  • Fax: 203-429-8628

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: