Provider Demographics
NPI:1396966453
Name:GRIMM, LARRY L (EDD)
Entity type:Individual
Prefix:DR
First Name:LARRY
Middle Name:L
Last Name:GRIMM
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 11255
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86304-1255
Mailing Address - Country:US
Mailing Address - Phone:928-443-0428
Mailing Address - Fax:928-443-0454
Practice Address - Street 1:222 S. SUMMIT AVE., STE. 1
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86303-3780
Practice Address - Country:US
Practice Address - Phone:928-443-0428
Practice Address - Fax:928-443-0454
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1195103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent