Healthcare Provider Details

I. General information

NPI: 1386197739
Provider Name (Legal Business Name): SHANE GRIGGS LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2016
Last Update Date: 08/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1352 E CENTER ST STE A
POCATELLO ID
83201-4773
US

IV. Provider business mailing address

28 WILLOWOOD AVE
POCATELLO ID
83204-4004
US

V. Phone/Fax

Practice location:
  • Phone: 208-233-2025
  • Fax: 208-233-2178
Mailing address:
  • Phone: 208-241-8207
  • Fax: 208-233-2178

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC-6279
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: