Healthcare Provider Details

I. General information

NPI: 1992051080
Provider Name (Legal Business Name): CAROLYN LEE GRINSTEAD LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2012
Last Update Date: 12/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 BAXTER DR
PAXTON MA
01612-1275
US

IV. Provider business mailing address

6 BAXTER DR
PAXTON MA
01612-1275
US

V. Phone/Fax

Practice location:
  • Phone: 508-799-5756
  • Fax:
Mailing address:
  • Phone: 508-799-5756
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number215704
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: