Provider Demographics
NPI:1821364258
Name:GRIMES, DARA M
Entity Type:Individual
Prefix:
First Name:DARA
Middle Name:M
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 1:158 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46307-4063
Mailing Address - Country:US
Mailing Address - Phone:219-663-0888
Mailing Address - Fax:
Practice Address - Street 1:2960 CHAIN BRIDGE RD STE 200
Practice Address - Street 2:
Practice Address - City:OAKTON
Practice Address - State:VA
Practice Address - Zip Code:22124-3040
Practice Address - Country:US
Practice Address - Phone:703-490-0336
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-29
Last Update Date:2020-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN87000970A101YA0400X
IN34006575A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200275200AMedicaid
IN200275200AMedicaid