Provider Demographics
NPI:1114089034
Name:GRIMES, GRACE (PSYD)
Entity Type:Individual
Prefix:MRS
First Name:GRACE
Middle Name:
Last Name:GRIMES
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:142 E. CALIFORNIA AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93706-3642
Mailing Address - Country:US
Mailing Address - Phone:559-600-1045
Mailing Address - Fax:559-600-1101
Practice Address - Street 1:142 E CALIFORNIA AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93706-3642
Practice Address - Country:US
Practice Address - Phone:559-600-1045
Practice Address - Fax:559-600-1101
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2015-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF38171101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA101YM0800XMedicare ID - Type Unspecified