Provider Demographics
NPI:1225078165
Name:GRIMM, GEOFFREY G (PHD)
Entity Type:Individual
Prefix:
First Name:GEOFFREY
Middle Name:G
Last Name:GRIMM
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:936 SHARPE HOSPITAL RD
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:WV
Mailing Address - Zip Code:26452-8550
Mailing Address - Country:US
Mailing Address - Phone:304-269-1210
Mailing Address - Fax:304-269-0457
Practice Address - Street 1:936 SHARPE HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:WV
Practice Address - Zip Code:26452-8550
Practice Address - Country:US
Practice Address - Phone:304-269-1210
Practice Address - Fax:304-269-0457
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV871103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVGRCP29621Medicare ID - Type UnspecifiedMEDICARE PROVIDER ID #
WVQ03392Medicare UPIN