Healthcare Provider Details

I. General information

NPI: 1417444910
Provider Name (Legal Business Name): MALLORY GRIMSTE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2018
Last Update Date: 12/12/2025
Certification Date: 12/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 HAZEL TER STE 12
WOODBRIDGE CT
06525-2240
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 Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: MALLORY ANNE GRIMSTE
Title or Position: OWNER
Credential: LCSW
Phone: 203-228-8971