Provider Demographics
NPI:1750835922
Name:GRIM, MICHELLE (MED, SP)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:GRIM
Suffix:
Gender:F
Credentials:MED, SP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:539 WINDSOR PARK DR
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45459-4112
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:539 WINDSOR PARK DR
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45459-4112
Practice Address - Country:US
Practice Address - Phone:937-409-6156
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-05
Last Update Date:2018-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP.00638103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist