Provider Demographics
NPI:1083786370
Name:GRIMMER, MARY B (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:B
Last Name:GRIMMER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3873 OLD DUNN RD
Mailing Address - Street 2:
Mailing Address - City:APOPKA
Mailing Address - State:FL
Mailing Address - Zip Code:32712-4788
Mailing Address - Country:US
Mailing Address - Phone:407-814-9433
Mailing Address - Fax:
Practice Address - Street 1:601 W MICHIGAN ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32805-6203
Practice Address - Country:US
Practice Address - Phone:407-317-7430
Practice Address - Fax:407-540-1925
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2012-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW 81961041C0700X
104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL7680899Medicaid
FL8117527 00Medicaid