Provider Demographics
NPI:1477168706
Name:GRIMM, HAYDEN JOE (PTA)
Entity Type:Individual
Prefix:
First Name:HAYDEN
Middle Name:JOE
Last Name:GRIMM
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5100 FRANKLIN AVE STE C
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76710-6922
Mailing Address - Country:US
Mailing Address - Phone:254-732-5981
Mailing Address - Fax:254-776-2667
Practice Address - Street 1:5100 FRANKLIN AVE STE C
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76710-6922
Practice Address - Country:US
Practice Address - Phone:254-732-5981
Practice Address - Fax:254-776-2667
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-14
Last Update Date:2020-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPENDINGOtherPENDING