Healthcare Provider Details

I. General information

NPI: 1225824667
Provider Name (Legal Business Name): SOPHIA GRIMMER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/15/2025
Last Update Date: 04/15/2025
Certification Date: 04/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 KAYS DR STE C
NORMAL IL
61761-1979
US

IV. Provider business mailing address

16171 SCENIC TRL
SPRING LAKE MI
49456-2273
US

V. Phone/Fax

Practice location:
  • Phone: 309-807-5077
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: