Healthcare Provider Details

I. General information

NPI: 1568657195
Provider Name (Legal Business Name): MICHELLE A GRIMM M.ED
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2007
Last Update Date: 09/06/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

504 LAKELAND RD
SHAWANO WI
54166-3836
US

IV. Provider business mailing address

504 LAKELAND RD
SHAWANO WI
54166-3836
US

V. Phone/Fax

Practice location:
  • Phone: 715-526-5547
  • Fax: 715-526-5542
Mailing address:
  • Phone: 715-526-5547
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number14267
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number3370125
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: