Basic Information
| Provider Information | |||||||||
| NPI: | 1790107514 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRIMSLEY | ||||||||
| FirstName: | SHANNON | ||||||||
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| Credential: | MS, NCC, LPCC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 201 SIMPSON AVE APT 411 | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405044125 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2406676348 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10102 COUNTRY CLUB ROAD | ||||||||
| Address2: | |||||||||
| City: | CUMBERLAND | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3017772290 | ||||||||
| FaxNumber: | 3017772160 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/14/2014 | ||||||||
| LastUpdateDate: | 05/28/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | LCA1993 | MD | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YP2500X | LC5025 | MD | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101YP2500X | 241824 | KY | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.