Healthcare Provider Details

I. General information

NPI: 1912634338
Provider Name (Legal Business Name): ASHLYN GRIMM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2022
Last Update Date: 07/17/2023
Certification Date: 07/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

731 PRE EMPTION RD
GENEVA NY
14456-1335
US

IV. Provider business mailing address

731 PRE EMPTION RD
GENEVA NY
14456-1335
US

V. Phone/Fax

Practice location:
  • Phone: 315-789-6828
  • Fax:
Mailing address:
  • Phone: 315-789-6828
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number032146-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: