Healthcare Provider Details

I. General information

NPI: 1447793468
Provider Name (Legal Business Name): BRETT GRIMM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/22/2016
Last Update Date: 12/10/2024
Certification Date: 12/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

474 W 200 N
ST GEORGE UT
84770-4505
US

IV. Provider business mailing address

474 W 200 N
ST GEORGE UT
84770-4505
US

V. Phone/Fax

Practice location:
  • Phone: 435-634-5600
  • Fax:
Mailing address:
  • Phone: 435-634-5600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number10110602-3502
License Number StateUT

VII. Legacy identifiers

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

# 1
Identifier10110602-3502
Identifier TypeMEDICAID
Identifier StateUT
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: