=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366257214
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SARA SHABRINA GRIMISON
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/10/2025
-----------------------------------------------------
Last Update Date | 02/10/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 787 37TH ST STE E260
-----------------------------------------------------
City | VERO BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32960-7309
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-220-3439
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 103 ROSELYN AVE
-----------------------------------------------------
City | FORT PIERCE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34982-3440
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-475-7471
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------