Provider Demographics
NPI:1770921017
Name:GRIMM, ERIN SHAWNNA (MFT)
Entity type:Individual
Prefix:
First Name:ERIN
Middle Name:SHAWNNA
Last Name:GRIMM
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:317 DEWITT ST
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:WI
Mailing Address - Zip Code:53901-2155
Mailing Address - Country:US
Mailing Address - Phone:608-745-1751
Mailing Address - Fax:608-745-1757
Practice Address - Street 1:317 DEWITT ST
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:WI
Practice Address - Zip Code:53901-2155
Practice Address - Country:US
Practice Address - Phone:608-745-1751
Practice Address - Fax:608-745-1757
Is Sole Proprietor?:No
Enumeration Date:2013-06-10
Last Update Date:2013-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI341-228106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist