Healthcare Provider Details

I. General information

NPI: 1174130207
Provider Name (Legal Business Name): MS. MCKENZIE GRIM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2020
Last Update Date: 09/23/2020
Certification Date: 09/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

916 MOUNTAIN VIEW RD
RAPID CITY SD
57702-2521
US

IV. Provider business mailing address

5321 S BREEZEWAY AVE
SIOUX FALLS SD
57108-8347
US

V. Phone/Fax

Practice location:
  • Phone: 888-365-6271
  • Fax:
Mailing address:
  • Phone: 605-553-6223
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number5113
License Number StateSD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: