Provider Demographics
NPI:1295939502
Name:GRISWOLD, EMMETT LEE
Entity type:Individual
Prefix:
First Name:EMMETT
Middle Name:LEE
Last Name:GRISWOLD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P O BOX 1827
Mailing Address - Street 2:
Mailing Address - City:MILLEDGEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31059-1827
Mailing Address - Country:US
Mailing Address - Phone:478-445-4721
Mailing Address - Fax:478-445-6769
Practice Address - Street 1:430 N JEFFERSON ST NE
Practice Address - Street 2:
Practice Address - City:MILLEDGEVILLE
Practice Address - State:GA
Practice Address - Zip Code:31061-2919
Practice Address - Country:US
Practice Address - Phone:478-445-4721
Practice Address - Fax:478-445-6769
Is Sole Proprietor?:No
Enumeration Date:2007-06-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0007621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical