Healthcare Provider Details

I. General information

NPI: 1063236362
Provider Name (Legal Business Name): DESTINEE CHENILLE GRIMMETT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/13/2024
Last Update Date: 04/29/2026
Certification Date: 04/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1323 CHAMPLAIN ST
TOLEDO OH
43604-2041
US

IV. Provider business mailing address

1323 CHAMPLAIN ST
TOLEDO OH
43604-2041
US

V. Phone/Fax

Practice location:
  • Phone: 567-252-8327
  • Fax: 419-442-7500
Mailing address:
  • Phone: 567-252-8327
  • Fax: 419-442-7500

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number193661
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: