Provider Demographics
NPI:1326588120
Name:GRIMES, ETHAN NATHANIEL
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:NATHANIEL
Last Name:GRIMES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 CISCO RD
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504-1143
Mailing Address - Country:US
Mailing Address - Phone:859-253-1686
Mailing Address - Fax:
Practice Address - Street 1:124 CISCO RD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-1143
Practice Address - Country:US
Practice Address - Phone:859-253-1686
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-28
Last Update Date:2017-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1790731081Medicaid