Provider Demographics
NPI:1992122477
Name:GROVE, SHANELLE (LMSW)
Entity type:Individual
Prefix:
First Name:SHANELLE
Middle Name:
Last Name:GROVE
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3865 S MACKINAC TRL
Mailing Address - Street 2:
Mailing Address - City:SAULT SAINTE MARIE
Mailing Address - State:MI
Mailing Address - Zip Code:49783-9286
Mailing Address - Country:US
Mailing Address - Phone:906-635-3775
Mailing Address - Fax:906-632-1163
Practice Address - Street 1:3865 S MACKINAC TRL
Practice Address - Street 2:
Practice Address - City:SAULT SAINTE MARIE
Practice Address - State:MI
Practice Address - Zip Code:49783-9286
Practice Address - Country:US
Practice Address - Phone:906-635-3775
Practice Address - Fax:906-632-1163
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-24
Last Update Date:2019-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
MI60811042501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker