Healthcare Provider Details

I. General information

NPI: 1932734357
Provider Name (Legal Business Name): ELIZABETH JODI GRIMALDI LLMFT, MDIV
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/05/2020
Last Update Date: 06/20/2022
Certification Date: 06/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

233 FULTON ST E STE 28
GRAND RAPIDS MI
49503-3262
US

IV. Provider business mailing address

2621 N TAMARACK DR
MIDLAND MI
48642-7887
US

V. Phone/Fax

Practice location:
  • Phone: 616-228-9244
  • Fax: 616-327-6333
Mailing address:
  • Phone: 989-948-3503
  • Fax: 616-327-6333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number4101006921
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number4101007262
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: