Provider Demographics
NPI:1750658753
Name:GRIMES, THERESA M (MS/CCC-SLP)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:M
Last Name:GRIMES
Suffix:
Gender:F
Credentials:MS/CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 DOGWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:FARMINGVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11738-1724
Mailing Address - Country:US
Mailing Address - Phone:631-987-1158
Mailing Address - Fax:
Practice Address - Street 1:51 DOGWOOD AVE
Practice Address - Street 2:
Practice Address - City:FARMINGVILLE
Practice Address - State:NY
Practice Address - Zip Code:11738-1724
Practice Address - Country:US
Practice Address - Phone:631-987-1158
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-19
Last Update Date:2011-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015454-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist