Provider Demographics
NPI:1144538620
Name:GRISWOLD, SHANNON FRANCES (PSYD)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:FRANCES
Last Name:GRISWOLD
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:314 S MIRALESTE DR UNIT 120
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90732-3005
Mailing Address - Country:US
Mailing Address - Phone:828-545-9502
Mailing Address - Fax:
Practice Address - Street 1:314 S MIRALESTE DR UNIT 120
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90732-3005
Practice Address - Country:US
Practice Address - Phone:828-545-9502
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-19
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
PAPS017621103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health