Provider Demographics
NPI:1952414138
Name:GRIMMELL, DEREK (PHD)
Entity Type:Individual
Prefix:DR
First Name:DEREK
Middle Name:
Last Name:GRIMMELL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1523 S BLUFF BLVD
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:IA
Mailing Address - Zip Code:52732-6549
Mailing Address - Country:US
Mailing Address - Phone:563-243-6054
Mailing Address - Fax:563-243-6828
Practice Address - Street 1:3 29TH CT
Practice Address - Street 2:
Practice Address - City:HUTCHINSON
Practice Address - State:KS
Practice Address - Zip Code:67502-2417
Practice Address - Country:US
Practice Address - Phone:620-259-7866
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2016-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE519103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA24558OtherMIDLANDS
IA38434OtherBCBS
IAI14475Medicare ID - Type UnspecifiedMEDICARE