MEDICARE: DR. KIM MARIE GRUM LSUDC, CAADC, CRS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	13939693	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0284366000	OTHER	PA	INDEPENDENCE BLUE CROSS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	447982	OTHER	PA	HIGHMARK BLUE SHIELD
5	1015164	OTHER	PA	KEYSTONE MERCY

General Provider Information

NPI Number	:	1649271933
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KIM MARIE GRUM LSUDC, CAADC, CRS

Provider Business Mailing Address
First Line	:	2512 GOLDEN SANDS DR
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89128-6801
Country	:	US
Telephone Number	:	215-919-1558
Fax Number	:	215-491-1750

Provider Business Practice Location Address
First Line	:	2512 GOLDEN SANDS DR
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89128-6801
Country	:	US
Telephone Number	:	215-919-1558
Fax Number	:	215-491-1750

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/09/2005
Last Update Date	:	01/24/2025

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Directions to “ DR. KIM MARIE GRUM LSUDC, CAADC, CRS” Practice Location

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