Provider Demographics
NPI:1629501531
Name:GROSSNICKLE, COURTNEY (LPC)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:GROSSNICKLE
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 1:11533 WOLFSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:MYERSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21773-8805
Mailing Address - Country:US
Mailing Address - Phone:240-355-2443
Mailing Address - Fax:
Practice Address - Street 1:11533 WOLFSVILLE RD
Practice Address - Street 2:
Practice Address - City:MYERSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21773-8805
Practice Address - Country:US
Practice Address - Phone:240-355-2443
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-07
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701008061101YM0800X
MDLC11376101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health