Provider Demographics
NPI:1871003855
Name:GRUNDY, CHANEL Y (MS, LPC)
Entity type:Individual
Prefix:
First Name:CHANEL
Middle Name:Y
Last Name:GRUNDY
Suffix:
Gender:F
Credentials:MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 518
Mailing Address - Street 2:
Mailing Address - City:PRIMOS SECANE
Mailing Address - State:PA
Mailing Address - Zip Code:19018-0518
Mailing Address - Country:US
Mailing Address - Phone:484-206-5044
Mailing Address - Fax:
Practice Address - Street 1:914 SOUTH AVE APT C19
Practice Address - Street 2:
Practice Address - City:SECANE
Practice Address - State:PA
Practice Address - Zip Code:19018-4463
Practice Address - Country:US
Practice Address - Phone:484-206-5044
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-04
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC012465101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAQCH121643587001OtherINDEPENDENCE HEALTH PLAN EAST