Healthcare Provider Details

I. General information

NPI: 1538063235
Provider Name (Legal Business Name): SYREETA GRIGSBY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SYREETA JOHNSON

II. Dates (important events)

Enumeration Date: 10/06/2026
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4415 RIDGEDALE DR
MESQUITE TX
75150-1647
US

IV. Provider business mailing address

4415 RIDGEDALE DR
MESQUITE TX
75150-1647
US

V. Phone/Fax

Practice location:
  • Phone: 469-620-0383
  • Fax:
Mailing address:
  • Phone: 469-620-0383
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number69244
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: