Healthcare Provider Details

I. General information

NPI: 1083786370
Provider Name (Legal Business Name): MARY B GRIMMER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 04/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 W MICHIGAN ST
ORLANDO FL
32805-6203
US

IV. Provider business mailing address

3873 OLD DUNN RD
APOPKA FL
32712-4788
US

V. Phone/Fax

Practice location:
  • Phone: 407-317-7430
  • Fax: 407-540-1925
Mailing address:
  • Phone: 407-814-9433
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW 8196
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: