Provider Demographics
NPI:1386197739
Name:GRIGGS, SHANE (LPC)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:
Last Name:GRIGGS
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 WILLOWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83204-4004
Mailing Address - Country:US
Mailing Address - Phone:208-241-8207
Mailing Address - Fax:208-233-2178
Practice Address - Street 1:1352 E CENTER ST STE A
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4773
Practice Address - Country:US
Practice Address - Phone:208-233-2025
Practice Address - Fax:208-233-2178
Is Sole Proprietor?:No
Enumeration Date:2016-08-02
Last Update Date:2016-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-6279101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional