Provider Demographics
NPI:1265635544
Name:GRIMM, LISA MAE (MS)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MAE
Last Name:GRIMM
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 S HARVARD AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74112-1103
Mailing Address - Country:US
Mailing Address - Phone:918-636-0328
Mailing Address - Fax:
Practice Address - Street 1:7010 S YALE AVE STE 215
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-5743
Practice Address - Country:US
Practice Address - Phone:918-492-2554
Practice Address - Fax:918-494-9870
Is Sole Proprietor?:No
Enumeration Date:2007-06-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK103TC1900X, 1041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Not Answered1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool