Provider Demographics
NPI:1063857027
Name:GRIMES, AMANDA (LMP)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:GRIMES
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 E BIRCH ST
Mailing Address - Street 2:SUITE 5
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-3043
Mailing Address - Country:US
Mailing Address - Phone:509-440-1494
Mailing Address - Fax:509-769-0999
Practice Address - Street 1:214 E BIRCH ST
Practice Address - Street 2:SUITE 5
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-3043
Practice Address - Country:US
Practice Address - Phone:509-440-1494
Practice Address - Fax:509-769-0999
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-05
Last Update Date:2014-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60368164225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist