Provider Demographics
NPI:1861501405
Name:GRIMM, DONALD W (CP)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:W
Last Name:GRIMM
Suffix:
Gender:M
Credentials:CP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:773 PINE RIDGE CIR
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:CA
Mailing Address - Zip Code:92223-7153
Mailing Address - Country:US
Mailing Address - Phone:951-769-3288
Mailing Address - Fax:951-769-3288
Practice Address - Street 1:490 S FARRELL DR
Practice Address - Street 2:STE C207
Practice Address - City:PALM SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92262-7944
Practice Address - Country:US
Practice Address - Phone:760-699-6363
Practice Address - Fax:951-769-6753
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2017-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY-20305103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAS48849Medicare UPIN
CAOPL203050Medicare ID - Type Unspecified