Provider Demographics
NPI:1912217670
Name:GRIMES, BRENDA ANN (LISWS)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:ANN
Last Name:GRIMES
Suffix:
Gender:F
Credentials:LISWS
Other - Prefix:
Other - First Name:BRENDA
Other - Middle Name:ANN
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4200 PARK AVENUE
Mailing Address - Street 2:
Mailing Address - City:ASHTABULA
Mailing Address - State:OH
Mailing Address - Zip Code:44004
Mailing Address - Country:US
Mailing Address - Phone:440-992-8552
Mailing Address - Fax:440-992-6631
Practice Address - Street 1:4200 PARK AVENUE
Practice Address - Street 2:
Practice Address - City:ASHTABULA
Practice Address - State:OH
Practice Address - Zip Code:44004
Practice Address - Country:US
Practice Address - Phone:440-992-8552
Practice Address - Fax:440-992-6631
Is Sole Proprietor?:No
Enumeration Date:2010-10-15
Last Update Date:2010-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.0009117101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health