Provider Demographics
NPI:1558823682
Name:GRIMES, YANCEY W (LPC-INTERN)
Entity Type:Individual
Prefix:
First Name:YANCEY
Middle Name:W
Last Name:GRIMES
Suffix:
Gender:M
Credentials:LPC-INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2103 STONERIDGE DR
Mailing Address - Street 2:
Mailing Address - City:KELLER
Mailing Address - State:TX
Mailing Address - Zip Code:76248-5602
Mailing Address - Country:US
Mailing Address - Phone:817-797-5725
Mailing Address - Fax:
Practice Address - Street 1:1668 KELLER PKWY STE 200
Practice Address - Street 2:
Practice Address - City:KELLER
Practice Address - State:TX
Practice Address - Zip Code:76248-3711
Practice Address - Country:US
Practice Address - Phone:817-797-5725
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-06
Last Update Date:2019-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX81281101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional