Provider Demographics
NPI:1225742638
Name:GRANTHAM, SHELLY ANN (LPC)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:ANN
Last Name:GRANTHAM
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6400 BARRIE RD APT 970
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-2300
Mailing Address - Country:US
Mailing Address - Phone:612-913-0017
Mailing Address - Fax:
Practice Address - Street 1:6400 BARRIE RD APT 970
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-2300
Practice Address - Country:US
Practice Address - Phone:612-913-0017
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-10
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT3324101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional