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General NPI Number Information
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NPI Number | 1649661984
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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 | 02/09/2015
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Last Update Date | 02/09/2015
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Provider Practice Location Address
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Address Line | 685 MAIN ST SUITE C
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City | SAFETY HARBOR
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State | FL
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Zip | 34695-3562
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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 | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 2514MT
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License Number State | FL
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