Healthcare Provider Details

I. General information

NPI: 1083394258
Provider Name (Legal Business Name): KAITLYN GRIMES PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2023
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 S CREASY LN STE 2160
LAFAYETTE IN
47905-0763
US

IV. Provider business mailing address

2122 YORK RD STE 300
OAK BROOK IL
60523-1925
US

V. Phone/Fax

Practice location:
  • Phone: 765-607-6918
  • Fax:
Mailing address:
  • Phone: 765-607-6918
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-23-285712
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number05016534A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: