Provider Demographics
NPI:1902927098
Name:GRISSETT, ROSALYNN
Entity Type:Individual
Prefix:
First Name:ROSALYNN
Middle Name:
Last Name:GRISSETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1307 E 88TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60619-7028
Mailing Address - Country:US
Mailing Address - Phone:312-834-3642
Mailing Address - Fax:
Practice Address - Street 1:1307 E 88TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60619-7028
Practice Address - Country:US
Practice Address - Phone:312-834-3642
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2024-01-19
Deactivation Date:2021-12-15
Deactivation Code:
Reactivation Date:2023-12-19
Provider Licenses
StateLicense IDTaxonomies
IL150.112168104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty