Healthcare Provider Details

I. General information

NPI: 1962916817
Provider Name (Legal Business Name): SHANA NICOLE GRIMES LGSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/29/2017
Last Update Date: 11/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 STAFFORD RD
BARSTOW MD
20610-2061
US

IV. Provider business mailing address

920 JUDGE CT E
WEST RIVER MD
20778-2001
US

V. Phone/Fax

Practice location:
  • Phone: 410-535-4300
  • Fax: 410-535-3079
Mailing address:
  • Phone: 512-788-3232
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number23403
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: