Provider Demographics
NPI:1841955671
Name:GRIMM, NATHANIEL VINCENT (MS, LAT, ATC)
Entity type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:VINCENT
Last Name:GRIMM
Suffix:
Gender:M
Credentials:MS, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:454 DUNWOODY XING
Mailing Address - Street 2:
Mailing Address - City:WEBSTER
Mailing Address - State:NY
Mailing Address - Zip Code:14580-9449
Mailing Address - Country:US
Mailing Address - Phone:585-645-8640
Mailing Address - Fax:
Practice Address - Street 1:19401 CRYSTAL ROCK DR
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:MD
Practice Address - Zip Code:20874-1593
Practice Address - Country:US
Practice Address - Phone:585-645-8640
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-06
Last Update Date:2022-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01260034992255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer