Provider Demographics
NPI:1952473498
Name:GRIMM, MARIANN ELIZABETH (MA)
Entity Type:Individual
Prefix:
First Name:MARIANN
Middle Name:ELIZABETH
Last Name:GRIMM
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:MARIANN
Other - Middle Name:ELIZABETH
Other - Last Name:BROOKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:860 CAMBRIDGE CT
Mailing Address - Street 2:
Mailing Address - City:DUNEDIN
Mailing Address - State:FL
Mailing Address - Zip Code:34698-6101
Mailing Address - Country:US
Mailing Address - Phone:727-504-4126
Mailing Address - Fax:727-216-3998
Practice Address - Street 1:860 CAMBRIDGE CT
Practice Address - Street 2:
Practice Address - City:DUNEDIN
Practice Address - State:FL
Practice Address - Zip Code:34698-6101
Practice Address - Country:US
Practice Address - Phone:727-504-4126
Practice Address - Fax:727-216-3998
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2014-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0680000240 LCMHC101YM0800X
VT1000000018106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004323600Medicaid