Healthcare Provider Details

I. General information

NPI: 1629501531
Provider Name (Legal Business Name): COURTNEY GROSSNICKLE LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/07/2017
Last Update Date: 07/14/2021
Certification Date: 07/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11533 WOLFSVILLE RD
MYERSVILLE MD
21773-8805
US

IV. Provider business mailing address

11533 WOLFSVILLE RD
MYERSVILLE MD
21773-8805
US

V. Phone/Fax

Practice location:
  • Phone: 240-355-2443
  • Fax:
Mailing address:
  • Phone: 240-355-2443
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0701008061
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLC11376
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: