MEDICARE: MRS. GEORGIA GRIMES LMFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	1164	LA
2	106H00000X	Marriage & Family Therapist	831	LA

General Provider Information

NPI Number	:	1295071843
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. GEORGIA GRIMES LMFT

Provider Business Mailing Address
First Line	:	14635 S HARRELLS FERRY RD
Second Line	:	STE. 3-A
City	:	BATON ROUGE
State	:	LA
Zip	:	70816-2959
Country	:	US
Telephone Number	:	225-751-5412
Fax Number	:	225-751-5847

Provider Business Practice Location Address
First Line	:	14635 S HARRELLS FERRY RD
Second Line	:	STE. 3-A
City	:	BATON ROUGE
State	:	LA
Zip	:	70816-2959
Country	:	US
Telephone Number	:	225-751-5412
Fax Number	:	225-751-5847

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/28/2012
Last Update Date	:	12/28/2012

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