MEDICARE: ERIN SHAWNNA GRIMM MFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	341-228	WI

General Provider Information

NPI Number	:	1770921017
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ERIN SHAWNNA GRIMM MFT

Provider Business Mailing Address
First Line	:	317 DEWITT ST
Second Line	:
City	:	PORTAGE
State	:	WI
Zip	:	53901-2155
Country	:	US
Telephone Number	:	608-745-1751
Fax Number	:	608-745-1757

Provider Business Practice Location Address
First Line	:	317 DEWITT ST
Second Line	:
City	:	PORTAGE
State	:	WI
Zip	:	53901-2155
Country	:	US
Telephone Number	:	608-745-1751
Fax Number	:	608-745-1757

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/10/2013
Last Update Date	:	06/10/2013

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