Healthcare Provider Details

I. General information

NPI: 1366958688
Provider Name (Legal Business Name): KYLE GRIMM LMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/22/2017
Last Update Date: 10/22/2021
Certification Date: 10/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1515 N 1ST ST
INDIANOLA IA
50125-3703
US

IV. Provider business mailing address

1515 N 1ST ST
INDIANOLA IA
50125-3703
US

V. Phone/Fax

Practice location:
  • Phone: 515-306-3423
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: