Provider Demographics
NPI:1225262298
Name:GRIMES, COURTNEY (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:GRIMES
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 ROBINSON DR
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92782-1095
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1301 W PROVIDENCE AVE
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-3808
Practice Address - Country:US
Practice Address - Phone:714-923-1521
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-06
Last Update Date:2009-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15653235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist