Healthcare Provider Details

I. General information

NPI: 1386411338
Provider Name (Legal Business Name): LAUREN GRISWOLD LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2023
Last Update Date: 12/11/2023
Certification Date: 12/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

213 NW 10TH ST STE A
FAIRFIELD IL
62837-1219
US

IV. Provider business mailing address

213 NW 10TH ST STE A
FAIRFIELD IL
62837-1219
US

V. Phone/Fax

Practice location:
  • Phone: 618-842-4617
  • Fax:
Mailing address:
  • Phone: 618-842-4617
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149016970
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: