MEDICARE: MARISSA GRIGGS PH.D.

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	103TC0700X	Clinical Psychologist	103062	NC

General Provider Information

NPI Number	:	1922404839
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARISSA GRIGGS PH.D.

Provider Business Mailing Address
First Line	:	2905 BRIARCLIFFE RD
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27106-3076
Country	:	US
Telephone Number	:	336-722-5890
Fax Number	:

Provider Business Practice Location Address
First Line	:	2905 BRIARCLIFFE RD
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27106-3076
Country	:	US
Telephone Number	:	336-722-5890
Fax Number	:

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

Provider Enumeration Date	:	11/05/2014
Last Update Date	:	11/05/2014

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