Provider Demographics
NPI:1043631955
Name:GRIMM, EMILY
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:GRIMM
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 1:426 W SURF ST APT 612
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-6135
Mailing Address - Country:US
Mailing Address - Phone:847-431-8022
Mailing Address - Fax:
Practice Address - Street 1:426 W SURF ST APT 612
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-6135
Practice Address - Country:US
Practice Address - Phone:847-431-8022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-18
Last Update Date:2013-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070020463225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist