Provider Demographics
NPI:1053430363
Name:GRIGSBY, LEE ANN (BA)
Entity type:Individual
Prefix:
First Name:LEE
Middle Name:ANN
Last Name:GRIGSBY
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3270 SUNTREE BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32940-7530
Mailing Address - Country:US
Mailing Address - Phone:321-264-4062
Mailing Address - Fax:321-264-4060
Practice Address - Street 1:3270 SUNTREE BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940-7530
Practice Address - Country:US
Practice Address - Phone:321-264-4062
Practice Address - Fax:321-264-4060
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL7602758Medicaid