Provider Demographics
NPI:1083485528
Name:GRIMMIUS, MARISA ANN (MA, LCMHCA, NCC)
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:ANN
Last Name:GRIMMIUS
Suffix:
Gender:F
Credentials:MA, LCMHCA, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15115 OXFORD HOLW
Mailing Address - Street 2:
Mailing Address - City:HUNTERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28078-5511
Mailing Address - Country:US
Mailing Address - Phone:910-528-0477
Mailing Address - Fax:
Practice Address - Street 1:111 KILSON DR STE 201
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-8218
Practice Address - Country:US
Practice Address - Phone:704-664-1009
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-12
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA19569101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCA19569OtherNORTH CAROLINA BOARD OF CLINICAL MENTAL HEALTH COUNSELORS