Healthcare Provider Details

I. General information

NPI: 1679210850
Provider Name (Legal Business Name): KOURTNEY GRIMSTAD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2022
Last Update Date: 06/07/2022
Certification Date: 06/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1514 JEFFERSON HWY
JEFFERSON LA
70121-2429
US

IV. Provider business mailing address

319 S LOPEZ ST APT B
NEW ORLEANS LA
70119-6251
US

V. Phone/Fax

Practice location:
  • Phone: 866-624-7637
  • Fax:
Mailing address:
  • Phone: 720-841-8156
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: