Healthcare Provider Details

I. General information

NPI: 1295939502
Provider Name (Legal Business Name): EMMETT LEE GRISWOLD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

430 N JEFFERSON ST NE
MILLEDGEVILLE GA
31061-2919
US

IV. Provider business mailing address

P O BOX 1827
MILLEDGEVILLE GA
31059-1827
US

V. Phone/Fax

Practice location:
  • Phone: 478-445-4721
  • Fax: 478-445-6769
Mailing address:
  • Phone: 478-445-4721
  • Fax: 478-445-6769

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW000762
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: