Provider Demographics
NPI:1649271933
Name:GRUM, KIM MARIE (LSUDC, CAADC, CRS)
Entity type:Individual
Prefix:DR
First Name:KIM
Middle Name:MARIE
Last Name:GRUM
Suffix:
Gender:F
Credentials:LSUDC, CAADC, CRS
Other - Prefix:DR
Other - First Name:KIM
Other - Middle Name:MARIE
Other - Last Name:ABDALLA-DIGIACOMO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPM
Mailing Address - Street 1:2512 GOLDEN SANDS DR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128-6801
Mailing Address - Country:US
Mailing Address - Phone:215-919-1558
Mailing Address - Fax:215-491-1750
Practice Address - Street 1:2512 GOLDEN SANDS DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-6801
Practice Address - Country:US
Practice Address - Phone:215-919-1558
Practice Address - Fax:215-491-1750
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-09
Last Update Date:2025-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13939693101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0284366000OtherINDEPENDENCE BLUE CROSS
PA07802520Medicaid
UT1649271933Medicaid
PA447982OtherHIGHMARK BLUE SHIELD
PA1015164OtherKEYSTONE MERCY
PA447982Medicare ID - Type Unspecified
PA0284366000OtherINDEPENDENCE BLUE CROSS