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General NPI Number Information
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NPI Number | 1134596968
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Entity Type | Organization
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Legal Business Name | MIMIGRIMM,MA,INDIVIDUAL,COUPLE&FAMILY THERAPY
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Dates
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Enumeration Date | 08/27/2015
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Last Update Date | 09/08/2015
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Provider Practice Location Address
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Address Line | 1000 BASS BLVD
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City | DUNEDIN
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State | FL
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Zip | 34698-2546
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Country | US
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Telephone | 727-504-4126
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Fax | 727-216-3998
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Provider Business Mailing Address
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Address Line | 860 CAMBRIDGE CT
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City | DUNEDIN
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State | FL
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Zip | 34698-6101
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Country | US
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Telephone | 727-504-4126
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Fax | 727-216-3998
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Authorized Official
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Title or Position | MARRIAGE AND FAMILY THERAPIST
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Name | MARIANN ELIZABETH GRIMM
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Credential | MA
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Telephone | 727-504-4126
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | MT2514
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License Number State | FL
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