Provider Demographics
NPI:1487126918
Name:GRIDIRON, SHANELL
Entity type:Individual
Prefix:
First Name:SHANELL
Middle Name:
Last Name:GRIDIRON
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:SHANELL
Other - Middle Name:
Other - Last Name:GRIDIRON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SHIPMAN
Mailing Address - Street 1:2525 N CHESTER AVE STE C
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93308-1770
Mailing Address - Country:US
Mailing Address - Phone:661-868-7499
Mailing Address - Fax:661-868-0841
Practice Address - Street 1:2525 N CHESTER AVE STE C
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93308-1770
Practice Address - Country:US
Practice Address - Phone:661-868-7499
Practice Address - Fax:661-868-4898
Is Sole Proprietor?:No
Enumeration Date:2018-12-21
Last Update Date:2020-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101Y00000XBehavioral Health & Social Service ProvidersCounselor