Provider Demographics
NPI:1760028880
Name:GRIMES, KATHRYN
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:
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 1:403 N BOUGHTON ST
Mailing Address - Street 2:
Mailing Address - City:WATSEKA
Mailing Address - State:IL
Mailing Address - Zip Code:60970-1405
Mailing Address - Country:US
Mailing Address - Phone:815-383-7461
Mailing Address - Fax:
Practice Address - Street 1:1101 E WINTER AVE
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61832-2295
Practice Address - Country:US
Practice Address - Phone:217-651-6801
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-24
Last Update Date:2019-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150104071101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor