=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376358937
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOSEPH GRANGER GRIMSLEY IV RMHCI
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/11/2025
-----------------------------------------------------
Last Update Date | 02/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 365 WEKIVA SPRINGS RD STE 231
-----------------------------------------------------
City | LONGWOOD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32779-3690
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-488-7262
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2100 FOREST CIR
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32803-6290
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-488-7262
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | IMH27218
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------