Provider Demographics
NPI:1164615662
Name:GRIMES SHUMATE, TRACY (OT)
Entity Type:Individual
Prefix:MS
First Name:TRACY
Middle Name:
Last Name:GRIMES SHUMATE
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 S MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:VINTON
Mailing Address - State:VA
Mailing Address - Zip Code:24179-2522
Mailing Address - Country:US
Mailing Address - Phone:540-266-6950
Mailing Address - Fax:540-343-3982
Practice Address - Street 1:204 S MAPLE ST
Practice Address - Street 2:
Practice Address - City:VINTON
Practice Address - State:VA
Practice Address - Zip Code:24179-2522
Practice Address - Country:US
Practice Address - Phone:540-266-6950
Practice Address - Fax:540-343-3982
Is Sole Proprietor?:No
Enumeration Date:2007-08-20
Last Update Date:2007-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119002297225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0119002297OtherLICENSE