Provider Demographics
NPI:1689377673
Name:GRIMES, DARA NATAKA ADESIMBO (MED)
Entity Type:Individual
Prefix:
First Name:DARA
Middle Name:NATAKA ADESIMBO
Last Name:GRIMES
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6359 PATTERSON RD
Mailing Address - Street 2:
Mailing Address - City:SNOW CAMP
Mailing Address - State:NC
Mailing Address - Zip Code:27349-9015
Mailing Address - Country:US
Mailing Address - Phone:336-814-1731
Mailing Address - Fax:
Practice Address - Street 1:108 N FAYETTEVILLE ST
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:NC
Practice Address - Zip Code:27298-3203
Practice Address - Country:US
Practice Address - Phone:336-814-1731
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-27
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No175T00000XOther Service ProvidersPeer Specialist