Provider Demographics
NPI:1083633689
Name:GRIM, CRYSTAL BRADY (MS, CCC-A)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:BRADY
Last Name:GRIM
Suffix:
Gender:F
Credentials:MS, CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 BELLE TRACE RD
Mailing Address - Street 2:
Mailing Address - City:LECOMPTE
Mailing Address - State:LA
Mailing Address - Zip Code:71346-4730
Mailing Address - Country:US
Mailing Address - Phone:318-776-7668
Mailing Address - Fax:
Practice Address - Street 1:2495 SHREVEPORT HWY
Practice Address - Street 2:
Practice Address - City:PINEVILLE
Practice Address - State:LA
Practice Address - Zip Code:71360-4044
Practice Address - Country:US
Practice Address - Phone:318-473-0010
Practice Address - Fax:318-483-5117
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA4326231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist