Healthcare Provider Details

I. General information

NPI: 1023689965
Provider Name (Legal Business Name): SOPHIA GRIMM OTD, OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2021
Last Update Date: 07/01/2021
Certification Date: 07/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1330 QUAIL LAKE LOOP STE 200
COLORADO SPRINGS CO
80906-4651
US

IV. Provider business mailing address

566 OXBOW DR
MONUMENT CO
80132-6028
US

V. Phone/Fax

Practice location:
  • Phone: 719-540-2108
  • Fax:
Mailing address:
  • Phone: 719-433-9623
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOT.0006928
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: