Healthcare Provider Details

I. General information

NPI: 1184791873
Provider Name (Legal Business Name): MARC ANDERSON GRIMMETT PH.D., HSP-P
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3801 LAKE BOONE TRL
RALEIGH NC
27607-2934
US

IV. Provider business mailing address

4208 KNIGHTSBRIDGE WAY
RALEIGH NC
27604-8440
US

V. Phone/Fax

Practice location:
  • Phone: 919-784-9182
  • Fax:
Mailing address:
  • Phone: 919-622-3504
  • Fax: 919-515-6891

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number3145
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: