Healthcare Provider Details

I. General information

NPI: 1043789688
Provider Name (Legal Business Name): DYNESHA DIONE MASON-GRISSOM PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2018
Last Update Date: 01/21/2020
Certification Date: 01/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 GALEN DR STE 104
CHAMPAIGN IL
61821-7038
US

IV. Provider business mailing address

2500 GALEN DR STE 104
CHAMPAIGN IL
61821-7038
US

V. Phone/Fax

Practice location:
  • Phone: 217-693-6072
  • Fax:
Mailing address:
  • Phone: 217-693-6072
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: