Provider Demographics
NPI:1124534912
Name:GRINN, EXTASY (LCSW, CAP ICADC)
Entity Type:Individual
Prefix:
First Name:EXTASY
Middle Name:
Last Name:GRINN
Suffix:
Gender:F
Credentials:LCSW, CAP ICADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4799 PALMBROOKE CIR
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33417-7534
Mailing Address - Country:US
Mailing Address - Phone:561-876-8751
Mailing Address - Fax:
Practice Address - Street 1:2030 CHILHOWEE MEDICAL PARK
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37804-5285
Practice Address - Country:US
Practice Address - Phone:865-982-3400
Practice Address - Fax:865-238-2034
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-16
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLADC-003288-2014101YA0400X
FLSW148061041C0700X
TN7341104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical