Provider Demographics
NPI:1134596968
Name:MIMIGRIMM,MA,INDIVIDUAL,COUPLE&FAMILY THERAPY
Entity type:Organization
Organization Name:MIMIGRIMM,MA,INDIVIDUAL,COUPLE&FAMILY THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MARRIAGE AND FAMILY THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:MARIANN
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:GRIMM
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:727-504-4126
Mailing Address - Street 1:860 CAMBRIDGE CT
Mailing Address - Street 2:
Mailing Address - City:DUNEDIN
Mailing Address - State:FL
Mailing Address - Zip Code:34698-6101
Mailing Address - Country:US
Mailing Address - Phone:727-504-4126
Mailing Address - Fax:727-216-3998
Practice Address - Street 1:1000 BASS BLVD
Practice Address - Street 2:
Practice Address - City:DUNEDIN
Practice Address - State:FL
Practice Address - Zip Code:34698-2546
Practice Address - Country:US
Practice Address - Phone:727-504-4126
Practice Address - Fax:727-216-3998
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-27
Last Update Date:2015-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMT2514106H00000X, 106H00000X
FLMT214261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL011891300Medicaid