=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871003855
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHANEL Y GRUNDY MS, LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/04/2017
-----------------------------------------------------
Last Update Date | 01/27/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 914 SOUTH AVE APT C19
-----------------------------------------------------
City | SECANE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19018-4463
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 484-206-5044
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 518
-----------------------------------------------------
City | PRIMOS SECANE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19018-0518
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 484-206-5044
-----------------------------------------------------
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 | PC012465
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------