Provider Demographics
NPI:1376034728
Name:GRIMES, TYREIA LOUISE (PRS)
Entity type:Individual
Prefix:MISS
First Name:TYREIA
Middle Name:LOUISE
Last Name:GRIMES
Suffix:
Gender:F
Credentials:PRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:326 GIRARD AVE NE
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44704-2142
Mailing Address - Country:US
Mailing Address - Phone:234-425-8911
Mailing Address - Fax:
Practice Address - Street 1:2180 ROMIG RD
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44320-3879
Practice Address - Country:US
Practice Address - Phone:234-334-3406
Practice Address - Fax:234-334-3456
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-22
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPS.000528175T00000X
171M00000X, 175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Single Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0490996Medicaid