=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790107514
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHANNON GRIMSLEY MS, LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/14/2014
-----------------------------------------------------
Last Update Date | 04/02/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 840 YELLOW HILL RD
-----------------------------------------------------
City | BIGLERVILLE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17307-9485
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 717-467-3687
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 840 YELLOW HILL RD
-----------------------------------------------------
City | BIGLERVILLE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17307-9485
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 717-467-3687
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | LC5025
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 241824
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | PC013461
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------