Provider Demographics
NPI:1912248139
Name:MARK S GRIMM, LCSW LLC
Entity Type:Organization
Organization Name:MARK S GRIMM, LCSW LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:GRIMM
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:303-716-8013
Mailing Address - Street 1:1707 COLE BLVD
Mailing Address - Street 2:SUITE 250
Mailing Address - City:GOLDEN
Mailing Address - State:CO
Mailing Address - Zip Code:80401-3220
Mailing Address - Country:US
Mailing Address - Phone:303-716-8013
Mailing Address - Fax:303-763-5495
Practice Address - Street 1:1707 COLE BLVD
Practice Address - Street 2:SUITE 250
Practice Address - City:GOLDEN
Practice Address - State:CO
Practice Address - Zip Code:80401-3220
Practice Address - Country:US
Practice Address - Phone:303-716-8013
Practice Address - Fax:303-763-5495
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-13
Last Update Date:2013-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9850171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO07101553Medicaid
83966Medicare UPIN
CO07101553Medicaid