Healthcare Provider Details

I. General information

NPI: 1952414138
Provider Name (Legal Business Name): DEREK GRIMMELL PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2006
Last Update Date: 09/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 29TH CT
HUTCHINSON KS
67502-2417
US

IV. Provider business mailing address

1523 S BLUFF BLVD
CLINTON IA
52732-6549
US

V. Phone/Fax

Practice location:
  • Phone: 620-259-7866
  • Fax:
Mailing address:
  • Phone: 563-243-6054
  • Fax: 563-243-6828

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number519
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: