Provider Demographics
NPI:1396837084
Name:GRIMES, SAMANTHA (MSW, LCS)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:GRIMES
Suffix:
Gender:F
Credentials:MSW, LCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:815 PAXON HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:BROOMALL
Mailing Address - State:PA
Mailing Address - Zip Code:19008-3421
Mailing Address - Country:US
Mailing Address - Phone:610-724-4973
Mailing Address - Fax:
Practice Address - Street 1:815 PAXON HOLLOW RD
Practice Address - Street 2:
Practice Address - City:BROOMALL
Practice Address - State:PA
Practice Address - Zip Code:19008-3421
Practice Address - Country:US
Practice Address - Phone:610-359-4320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2009-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASW124829104100000X
PACW0163801041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker