Provider Demographics
NPI:1326080292
Name:GROSSMAN, SHELLY M (AUD)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:M
Last Name:GROSSMAN
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:SHELLY
Other - Middle Name:M
Other - Last Name:GROSSMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3831 LOCKPORT ST STE C
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58503-5539
Mailing Address - Country:US
Mailing Address - Phone:701-751-2500
Mailing Address - Fax:701-751-0231
Practice Address - Street 1:3831 LOCKPORT ST STE C
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58503-5539
Practice Address - Country:US
Practice Address - Phone:701-751-2500
Practice Address - Fax:701-751-0231
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2023-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDH-0217237700000X
ND570231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND52523Medicaid
ND52523Medicaid
NDS18222Medicare UPIN