Provider Demographics
NPI:1881768224
Name:GRIMM, MARILEN MAMUYAC (OTR)
Entity type:Individual
Prefix:MRS
First Name:MARILEN
Middle Name:MAMUYAC
Last Name:GRIMM
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 W GLENOAKS BLVD
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91202-2813
Mailing Address - Country:US
Mailing Address - Phone:818-637-2127
Mailing Address - Fax:818-637-2127
Practice Address - Street 1:500 W. GLENOAKS BLVD.
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91202
Practice Address - Country:US
Practice Address - Phone:818-637-2127
Practice Address - Fax:818-637-2126
Is Sole Proprietor?:No
Enumeration Date:2006-11-18
Last Update Date:2010-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT 8425225X00000X, 225XN1300X, 225XE1200X
CAOT8425225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XN1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistNeurorehabilitation
No225XE1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistErgonomics
No225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand