Healthcare Provider Details

I. General information

NPI: 1255763397
Provider Name (Legal Business Name): NELL STANTON GRIMM LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2013
Last Update Date: 07/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4909 WATERS EDGE DR SUITE 100
RALEIGH NC
27606-2462
US

IV. Provider business mailing address

4909 WATERS EDGE DR SUITE 100
RALEIGH NC
27606-2462
US

V. Phone/Fax

Practice location:
  • Phone: 910-658-4464
  • Fax:
Mailing address:
  • Phone: 910-658-4464
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number8425
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: