Provider Demographics
NPI:1255955266
Name:GRISWOLD, SELENAANN MILICANT KRISTINE (MSW, LCSW)
Entity type:Individual
Prefix:
First Name:SELENAANN
Middle Name:MILICANT KRISTINE
Last Name:GRISWOLD
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:SELENAANN
Other - Middle Name:MILICANT KRISTINE
Other - Last Name:BALDWIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7362 W PARKS HWY # 339
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99623-9300
Mailing Address - Country:US
Mailing Address - Phone:907-671-2884
Mailing Address - Fax:907-600-5102
Practice Address - Street 1:124 W SWANSON AVE
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-6822
Practice Address - Country:US
Practice Address - Phone:907-671-2884
Practice Address - Fax:907-600-5102
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-04
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1795161041C0700X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical