Provider Demographics
NPI:1417515560
Name:GRIM, MARSHA KAY (COTA/L)
Entity Type:Individual
Prefix:
First Name:MARSHA
Middle Name:KAY
Last Name:GRIM
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 SWEDE POINT DR
Mailing Address - Street 2:
Mailing Address - City:MADRID
Mailing Address - State:IA
Mailing Address - Zip Code:50156-7614
Mailing Address - Country:US
Mailing Address - Phone:217-491-0838
Mailing Address - Fax:
Practice Address - Street 1:12251 HIGHWAY 41 N STE A
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47725-7043
Practice Address - Country:US
Practice Address - Phone:812-868-1224
Practice Address - Fax:186-671-5973
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-04
Last Update Date:2019-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA000862224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant