Provider Demographics
NPI:1467469635
Name:GRIMALDO, ROXANNA LEE (OTR)
Entity Type:Individual
Prefix:MS
First Name:ROXANNA
Middle Name:LEE
Last Name:GRIMALDO
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4501 OLD SPARTANBURG RD STE 7
Mailing Address - Street 2:
Mailing Address - City:TAYLORS
Mailing Address - State:SC
Mailing Address - Zip Code:29687-4105
Mailing Address - Country:US
Mailing Address - Phone:864-292-5154
Mailing Address - Fax:864-292-5151
Practice Address - Street 1:4501 OLD SPARTANBURG RD STE 7
Practice Address - Street 2:
Practice Address - City:TAYLORS
Practice Address - State:SC
Practice Address - Zip Code:29687-4105
Practice Address - Country:US
Practice Address - Phone:864-292-5154
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2018-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225XP0200X
SC3525225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1467469635Medicaid
SC225XPO200XMedicaid