Provider Demographics
NPI:1801385489
Name:GRISSO, THOMAS
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:GRISSO
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 1:4 CANDLEWOOD WAY
Mailing Address - Street 2:
Mailing Address - City:SHREWSBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01545-1728
Mailing Address - Country:US
Mailing Address - Phone:508-852-3950
Mailing Address - Fax:
Practice Address - Street 1:4 CANDLEWOOD WAY
Practice Address - Street 2:
Practice Address - City:SHREWSBURY
Practice Address - State:MA
Practice Address - Zip Code:01545-1728
Practice Address - Country:US
Practice Address - Phone:508-852-3950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-09
Last Update Date:2018-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4276103TF0200X
MA4278103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic