Provider Demographics
NPI:1962916817
Name:GRIMES, SHANA NICOLE (LGSW)
Entity type:Individual
Prefix:
First Name:SHANA
Middle Name:NICOLE
Last Name:GRIMES
Suffix:
Gender:F
Credentials:LGSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:920 JUDGE CT E
Mailing Address - Street 2:
Mailing Address - City:WEST RIVER
Mailing Address - State:MD
Mailing Address - Zip Code:20778-2001
Mailing Address - Country:US
Mailing Address - Phone:512-788-3232
Mailing Address - Fax:
Practice Address - Street 1:325 STAFFORD RD
Practice Address - Street 2:
Practice Address - City:BARSTOW
Practice Address - State:MD
Practice Address - Zip Code:20610-2061
Practice Address - Country:US
Practice Address - Phone:410-535-4300
Practice Address - Fax:410-535-3079
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-29
Last Update Date:2017-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD23403104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker