Healthcare Provider Details

I. General information

NPI: 1770073892
Provider Name (Legal Business Name): SHANNA L HARGROVE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2018
Last Update Date: 05/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

307 EAST ST
PLAINVILLE CT
06062-3417
US

IV. Provider business mailing address

200 BLAKESLEE ST APT 196
BRISTOL CT
06010-8803
US

V. Phone/Fax

Practice location:
  • Phone: 860-368-8665
  • Fax:
Mailing address:
  • Phone: 860-271-5270
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number008868
License Number StateCT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: