Healthcare Provider Details

I. General information

NPI: 1285282467
Provider Name (Legal Business Name): NICOLE AMELIA GRYWALSKI LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2019
Last Update Date: 09/03/2021
Certification Date: 06/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 BERKELEY ST FL 1
NORWALK CT
06850-3987
US

IV. Provider business mailing address

3 ROOSEVELT ST
NORWALK CT
06851-3014
US

V. Phone/Fax

Practice location:
  • Phone: 203-727-2015
  • Fax:
Mailing address:
  • Phone: 203-727-2015
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number4206
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number11437
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: