Healthcare Provider Details

I. General information

NPI: 1639626708
Provider Name (Legal Business Name): TIFFANY GRYMES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2016
Last Update Date: 09/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2323 TIMBER SHADOWS DR
KINGWOOD TX
77339-2028
US

IV. Provider business mailing address

PO BOX 5857
KINGWOOD TX
77325-5857
US

V. Phone/Fax

Practice location:
  • Phone: 832-233-3086
  • Fax: 832-201-8229
Mailing address:
  • Phone: 832-233-3086
  • Fax: 832-201-8229

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number74276
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: