Provider Demographics
NPI:1598524894
Name:GRIMES, DESIREE SHERISE
Entity Type:Individual
Prefix:
First Name:DESIREE
Middle Name:SHERISE
Last Name:GRIMES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1441 NE 136TH AVE APT 199
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98684-5981
Mailing Address - Country:US
Mailing Address - Phone:503-572-4424
Mailing Address - Fax:
Practice Address - Street 1:1441 NE 136TH AVE APT 199
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98684-5981
Practice Address - Country:US
Practice Address - Phone:503-572-4424
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-18
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR28209225700000X
NC21032225700000X
WAMA61531980225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist