Provider Demographics
NPI:1023090388
Name:GRIM, JANET MCCULLOUGH (MA LMFT PA)
Entity type:Individual
Prefix:MRS
First Name:JANET
Middle Name:MCCULLOUGH
Last Name:GRIM
Suffix:
Gender:F
Credentials:MA LMFT PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1726 KINGSLEY AVE
Mailing Address - Street 2:SUITE 3
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073
Mailing Address - Country:US
Mailing Address - Phone:904-269-7500
Mailing Address - Fax:904-269-9972
Practice Address - Street 1:1726 KINGSLEY AVE
Practice Address - Street 2:SUITE 3
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073
Practice Address - Country:US
Practice Address - Phone:904-269-7500
Practice Address - Fax:904-269-9972
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMT485106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
5971037OtherAETNA
10732102OtherCAQH
Z1385OtherBCBS