MEDICARE: STEPHANIE LYNNE GRIMES

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

General Provider Information

NPI Number	:	1952996043
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHANIE LYNNE GRIMES

Provider Business Mailing Address
First Line	:	700 E LAKE DR UNIT 46
Second Line	:
City	:	ORANGE
State	:	CA
Zip	:	92866-2756
Country	:	US
Telephone Number	:	657-340-7623
Fax Number	:

Provider Business Practice Location Address
First Line	:	700 E LAKE DR UNIT 46
Second Line	:
City	:	ORANGE
State	:	CA
Zip	:	92866-2756
Country	:	US
Telephone Number	:	657-340-7623
Fax Number	:

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

Provider Enumeration Date	:	03/02/2021
Last Update Date	:	03/02/2021

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