1649661984 NPI number — MIMIGRIMM MA INDIVIDUAL, COUPLE, & FAMILY THERAPY

Table of content: (NPI 1649661984)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649661984 NPI number — MIMIGRIMM MA INDIVIDUAL, COUPLE, & FAMILY THERAPY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MIMIGRIMM MA INDIVIDUAL, COUPLE, & FAMILY THERAPY
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1649661984
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/09/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
860 CAMBRIDGE CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DUNEDIN
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34698-6101
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
727-504-4126
Provider Business Mailing Address Fax Number:
727-216-3998

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
685 MAIN ST
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
SAFETY HARBOR
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34695-3562
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
727-504-4126
Provider Business Practice Location Address Fax Number:
727-216-3998
Provider Enumeration Date:
02/09/2015

Additional Information

Authorized Official

Authorized Official Last Name:
GRIMM
Authorized Official First Name:
MARIANN
Authorized Official Middle Name:
ELIZABETH
Authorized Official Title or Position:
MARRIAGE AND FAMILY THERAPIST
Authorized Official Telephone Number:
727-504-4126

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , with the licence number:  2514MT , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 779438 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com