Provider Demographics
NPI:1871655761
Name:GRIMES, NILDA SANTIAGO (LMFT)
Entity Type:Individual
Prefix:MS
First Name:NILDA
Middle Name:SANTIAGO
Last Name:GRIMES
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 CHERRY LANE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:MANTECA
Mailing Address - State:CA
Mailing Address - Zip Code:95337-4397
Mailing Address - Country:US
Mailing Address - Phone:209-832-9508
Mailing Address - Fax:209-832-9508
Practice Address - Street 1:250 CHERRY LANE
Practice Address - Street 2:SUITE 110
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95337-4397
Practice Address - Country:US
Practice Address - Phone:209-832-9508
Practice Address - Fax:209-832-9508
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA36368LMFT106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA10952635OtherCAQH