MEDICARE: KATHLEEN GRIZKY LCADC, CCS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	37LC00293200	NJ

General Provider Information

NPI Number	:	1649997529
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHLEEN GRIZKY LCADC, CCS

Provider Business Mailing Address
First Line	:	12 PENNSYLVANIA AVE
Second Line	:
City	:	DOROTHY
State	:	NJ
Zip	:	08317-9734
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	12 PENNSYLVANIA AVE
Second Line	:
City	:	DOROTHY
State	:	NJ
Zip	:	08317-9734
Country	:	US
Telephone Number	:	609-364-1255
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/21/2022
Last Update Date	:	10/21/2022

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