Healthcare Provider Details

I. General information

NPI: 1376051086
Provider Name (Legal Business Name): WILSON TYLER GRIMMETT MA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/16/2018
Last Update Date: 08/05/2024
Certification Date: 08/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 PRIVATE ROAD 977
PEDRO OH
45659-8608
US

IV. Provider business mailing address

115 PRIVATE ROAD 977
PEDRO OH
45659-8608
US

V. Phone/Fax

Practice location:
  • Phone: 740-534-1386
  • Fax:
Mailing address:
  • Phone: 740-534-1386
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: