Healthcare Provider Details

I. General information

NPI: 1124534912
Provider Name (Legal Business Name): EXTASY GRINN LCSW, CAP. ICADC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2017
Last Update Date: 07/09/2025
Certification Date: 07/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2030 CHILHOWEE MEDICAL PARK
MARYVILLE TN
37804-5285
US

IV. Provider business mailing address

4799 PALMBROOKE CIR
WEST PALM BEACH FL
33417-7534
US

V. Phone/Fax

Practice location:
  • Phone: 865-982-3400
  • Fax: 865-238-2034
Mailing address:
  • Phone: 561-876-8751
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberADC-003288-2014
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number7341
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW14806
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number7341
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: