Provider Demographics
NPI:1063009173
Name:GRIMM, KASSANDRA VATSANA (MS, LCGC)
Entity Type:Individual
Prefix:
First Name:KASSANDRA
Middle Name:VATSANA
Last Name:GRIMM
Suffix:
Gender:F
Credentials:MS, LCGC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 PENN SQ E STE 960
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-2724
Mailing Address - Country:US
Mailing Address - Phone:215-351-2331
Mailing Address - Fax:
Practice Address - Street 1:1 PENN SQ E STE 960
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-2724
Practice Address - Country:US
Practice Address - Phone:215-351-2331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-22
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV19446170300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS