Provider Demographics
NPI:1255355947
Name:GRIMES, REGINA LYNN (PT, C/NDT, ATP)
Entity type:Individual
Prefix:MRS
First Name:REGINA
Middle Name:LYNN
Last Name:GRIMES
Suffix:
Gender:F
Credentials:PT, C/NDT, ATP
Other - Prefix:MS
Other - First Name:REGINA
Other - Middle Name:LYNN
Other - Last Name:GRIMES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT, C/NDT, ATP
Mailing Address - Street 1:205 COUNTY ROAD 441
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:MS
Mailing Address - Zip Code:38851-7642
Mailing Address - Country:US
Mailing Address - Phone:662-231-1187
Mailing Address - Fax:662-448-1189
Practice Address - Street 1:205 COUNTY ROAD 441
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:MS
Practice Address - Zip Code:38851-7642
Practice Address - Country:US
Practice Address - Phone:662-231-1187
Practice Address - Fax:662-448-1189
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2020-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT24442251P0200X, 225100000X
MS74539225CA2400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225CA2400XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation CounselorAssistive Technology Practitioner
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01179084Medicaid