Healthcare Provider Details

I. General information

NPI: 1770921017
Provider Name (Legal Business Name): ERIN SHAWNNA GRIMM MFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2013
Last Update Date: 06/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

317 DEWITT ST
PORTAGE WI
53901-2155
US

IV. Provider business mailing address

317 DEWITT ST
PORTAGE WI
53901-2155
US

V. Phone/Fax

Practice location:
  • Phone: 608-745-1751
  • Fax: 608-745-1757
Mailing address:
  • Phone: 608-745-1751
  • Fax: 608-745-1757

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number341-228
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: