Provider Demographics
NPI:1770221020
Name:GRANDOLFO, SHELBY KAILIN
Entity type:Individual
Prefix:
First Name:SHELBY
Middle Name:KAILIN
Last Name:GRANDOLFO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 HARRIS AVE
Mailing Address - Street 2:
Mailing Address - City:RAEFORD
Mailing Address - State:NC
Mailing Address - Zip Code:28376-3112
Mailing Address - Country:US
Mailing Address - Phone:910-875-5590
Mailing Address - Fax:910-875-5008
Practice Address - Street 1:101 BRADFORD VILLAGE CT
Practice Address - Street 2:
Practice Address - City:SOUTHERN PINES
Practice Address - State:NC
Practice Address - Zip Code:28387-5451
Practice Address - Country:US
Practice Address - Phone:910-684-8750
Practice Address - Fax:910-725-0536
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-26
Last Update Date:2022-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical